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FUTURE MEETING SITE2013 Toronto, CanadaDecember 3-6, 2013
PAST ANNUAL MEETING SITES1972 Cincinnati
1973 Columbus
1974 LosAngeles
1975 Philadelphia
1979 NewYork
1980 NewYork
1981 Dallas
1982 SanFrancisco
1983 Toronto
1984 SaltLakeCity
1985 Houston
1986 Pittsburgh
1987 Chicago
1988 Scottsdale
1989 DistrictofColumbia
1990 SanDiego/PebbleBeach
1991 Boston
1992 Vancouver,BC
1993 SanAntonio
1994 St.Louis
1995 Pasadena
1996 Charleston
1997 NewOrleans
1998 Indianapolis
1999 Atlanta
2000 SanDiego
2001 NewYork
2002 Scottsdale
2003 SaltLakeCity
2004 SanFrancisco
2005 Orlando
2006 Denver
2007 SouthBeach(Miami)
2008 Spokane
2009 Boston
2010 Cleveland
2011 Austin
2012 St.Louis
2
NEW MEETING APP AVAILABLEForthefirsttime,theentireprogramisaccessibleviaournewApple/Androidcompatibleapp.Foryourconvenience,pleasevisittheappstoretodownloadthisuser-friendlyapplicationtoyourmobiledevice.The“Messages”linkwillprovideattendeeswithanychangesinprogramelectronically.
TABLE OF CONTENTSAnnualMeetingSites. . . . . . . . . . . . . . . . . . . . . . . 2
Accreditation/Designation . . . . . . . . . . . . . . . . . . . 3
AANS/CNSJointSectionofPediatricNeurologicalSurgeryOfficersandCommittees . . . . . . . . . . . . . . . 4
2012RaimondiLecture. . . . . . . . . . . . . . . . . . . . . . 6
AAP/SectiononNeurologicalSurgeons(SONS)Speaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
RaimondiLecturers . . . . . . . . . . . . . . . . . . . . . . . . . 7
MatsonMemorialLecturers. . . . . . . . . . . . . . . . . . . 7
FrancIngrahamAwardforDistinguishedServiceandAchievementRecipients . . . . . . . . . . . . . . . . . . 7
KennethShulmanAwardRecipients. . . . . . . . . . . . . 8
HydrocephalusAssociationAwardRecipients. . . . . . 9
MeetingRoomFloorPlan . . . . . . . . . . . . . . . . . . . 10
ExhibitHallFloorPlan . . . . . . . . . . . . . . . . . . . . . 11
ExhibitorListing. . . . . . . . . . . . . . . . . . . . . . . . . . 12
EducationalGrants. . . . . . . . . . . . . . . . . . . . . . . . 15
ProgramAt-A-Glance. . . . . . . . . . . . . . . . . . . . . . 16
DisclosureInformation . . . . . . . . . . . . . . . . . . . . . 17
Mid-LevelPractitioner’sSeminar . . . . . . . . . . . . . . . 19
AnnualMeetingProgram . . . . . . . . . . . . . . . . . . . 20
ScientificProgramOralAbstracts . . . . . . . . . . . . . . 30
ScientificProgramE-PosterAbstracts. . . . . . . . . . . . 52
SectionMembershipRoster . . . . . . . . . . . . . . . . . . 75
3
AANS/CNS SECTION ON PEDIATRIC NEUROLOGICAL SURGERYNovember 27-30, 2012St. Louis, Missouri
CONTINUING MEDICAL EDUCATION CREDITThisactivityhasbeenplannedandimplementedinaccordancewiththeEssentialAreasandpoliciesoftheAccreditationCouncilforContinuingMedicalEducationthroughthejointsponsorshipoftheAANSandtheAANS/CNSSectiononPediatricNeurologicalSurgery.TheAANSisaccreditedbytheACCMEtoprovidecontinuingmedicaleducationforphysicians.
TheAANSdesignatesthisliveactivityforamaximumof35.25AMA PRA Category 1 Credits™. Physiciansshouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.
Amaximumof15.75AMA PRA Category 1 Credits™canbeclaimedforgeneralsessionsandamaximumof19.50AMA PRA Category 1 Credits™canbeclaimedfortheticketedsessions.
FortheMid-LevelPractitioner’sSeminar:ThiscontinuingnursingeducationactivitywasapprovedbytheAmericanAssociationofNeuroscienceNurses(AANN),accreditedasanapproverofcontinuingeducationbytheAmericanNursesCredentialingCenter’sCOA.
JOINT SPONSORSHIP DISCLAIMERThematerialpresentedatthe2012AANS/CNSSectiononPediatricNeurologicalSurgeryAnnualMeetinghasbeenmadeavailablebytheAANS/CNSSectiononPediatricNeurologicalSurgeryandtheAANSforeducationalpurposesonly.Thematerialisnotintendedtorepresenttheonly,nornecessarilythebest,methodorprocedureappropriateformedicalsituationsdiscussed,butratherisintendedtopresentanapproach,view,statementoropinionofthefaculty,whichmaybehelpfultootherswhofacesimilarsituations.
Neitherthecontent(whetherwrittenororal)ofanycourse,seminarorotherpresentationintheprogram,northeuseofspecificproductinconjunctiontherewith,northeexhibitionofanymaterialsbyanypartiescoincidentwiththeprogram,shouldbeconstruedasindicatingendorsementorapprovaloftheviewspresented,theproductsusedorthematerialsexhibitedbytheAANS/CNSSectiononPediatricNeurologicalSurgeryandjointlysponsoredbytheAANS,oritsCommittees,CommissionsorAffiliates.
NeithertheAANSnortheAANS/CNSSectiononPediatricNeurologicalSurgerymakesanystatements,representationsorwarranties(whetherwrittenororal)regardingtheFoodandDrugAdministration(FDA)statusofanyproductusedorreferredtoinconjunctionwithanycourse,seminarorotherpresentationbeingmadeavailableaspartofthe2012AANS/CNSSectiononPediatricNeurologicalSurgeryAnnualMeeting.FacultymembersshallhavesoleresponsibilitytoinformattendeesoftheFDAstatusofeachproductthatisusedinconjunctionwithanycourse,seminarorpresentationandwhethersuchuseoftheproductisincompliancewithFDAregulations.
ANNUAL MEETING LEARNING OBJECTIVESUponcompletionofthisCMEactivity,participantsshouldbeableto: Reviewnationalqualityandsafetyinitiatives Discussupdatesonrecentadvancesinbraintumors,
spasticity,Chiarimalformationsandsyrinx Applyrecentadvancesinspineandendoscopytechniques Discusstheeconomicrealitiesofpracticingpediatric
neurosurgery
CLAIM CME CREDIT THE EASY WAYAgainthisyear,attendeeswillself-reportCMEcreditfortheprogramstheyattendbygoingonlinetoMyAANS.orgfromanycomputerwithinternetservice.PleasehaveyourMyAANS.orgusername[e-mailaddress]andpasswordhandyduringandafterthemeetingforconvenientcompletionandsubmission.
Donotself-reportCMEcreditfortheoptionalticketedevents;PracticalClinics,BreakfastSeminarsandMid-LevelPractitioner’sSeminar.Byturninginyourticketon-site,creditwillautomaticallybeaddedtoyourrecordinMyAANS.org.
WHO SHOULD ATTENDTheeducationalsessionswillbedirectedtowardspediatricneurologicalsurgeons,residents,nursecliniciansandphysicianassistantsandwillbedirectlyapplicabletotheirpractices.
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JOINT SECTION OF PEDIATRIC NEUROLOGICAL SURGERY OFFICERS AND COMMITTEES
STANDING COMMITTEESNominating CommitteeAnn-ChristineDuhaime,MD,Chair(2011)JeffreyH.Wisoff,MD,Chair(2009)RickAbbott,MD
Rules & Regulations CommitteeElizabethTyler-Kabara,MD,PhD,Chair(2010-2012)JohnC.WellonsIII,MD,Chair-elect(2010-2012)
Membership CommitteeDavidH.Harter,MD,Chair(2010-2012)RobinM.Bowman,MD,Vice-Chair(2010-2012)
Education CommitteeMarkD.Krieger,MD,Chair(2011-2013)GerryGrant,MD,Vice-Chair(2011-2013)
Pediatric Section Annual Meeting SubcommitteeJeffreyR.Leonard,MD,MatthewD.Smythe,MD,Co-Chairs
(2012,St.Louis)JamesDrake,MD,AbhayaV.Kulkavni,MD,JamesRutka,MD,
Co-Chairs(2013, Toronto)TimothyM.George,MD,ImmediatePastMeetingChair(2011,
Austin)ShenandoahRobinson,MD(2010,Cleveland)AlanR.Cohen,MD,Ex-OfficioMarkR.Proctor,MD,Ex-Officio
CURRENT OFFICERSAlanR.Cohen,MD,Chair(2011-2013)BruceA.Kaufman,MD,Chair-Elect(2011-2013)SarahJ.Gaskill,MD,Secretary(2011-2013)MarkR.Proctor,MD,Treasurer(2011-2013)Ann-ChristineDuhaime,MD,ImmediatePastChair(2011-2013)
MEMBERS AT LARGEBermansJ.Iskandar,MD(2011-2013)MarkSouwedaine,MD(2011-2013)LilianaC.Goumnerova,MD(2012-2014)GerryGrant,MD(2012-2014)
PEDIATRIC SECTION CHAIRS1972–73RobertL.McLaurin1973–74 M.PeterSayers1974–75FrankAnderson1975–76KennethShulman1976–77E.BruceHendrick1977–78FrankNulsen1978–79LuisSchut1979–81FredJ.Epstein1981–83 JoanL.Venes1983–85HaroldJ.Hoffman1985–87WilliamR.Cheek1987–89 DavidG.McLone1989–91 DonaldH.Reigel1991–93R.MichaelScott1993–95ArthurMarlin1995–97 HaroldL.Rekate1997–99MarionL.Walker1999–01JohnP.Laurent2001–03ThomasG.Luerssen2003–05AndrewD.Parent2005-07RickAbbott2007-09JeffreyH.Wisoff2009-11Ann-ChristineDuhaime2011-13AlanR.Cohen
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JOINT SECTION OF PEDIATRIC NEUROLOGICAL SURGERY OFFICERS AND COMMITTEES
REPRESENTATIVES AND LIAISONSLiaison to the AANS Executive CommitteeAlanR.Cohen,MD(2011-2013)
Liaison to the CNS Executive CommitteeBruceAKaufman,MD(2011-2013)
Liaison to the Washington Committee, AANS/CNSAnn-ChristineDuhaime,MD(2011-2013)
Liaison to the Wash. Communications Committee on Public RelationsCoreyRaffel,MD,PhD(2012)
Pediatric Section Representatives on the Joint Guidelines CommitteeAnnMarieFlannery,MD,Chair(2008-2012)AbhayaVivekKulkarni,MD(2010-2012)JayK.Riva-Cambrin,MD(2010-2012)
Liaison to Joint Section on TraumaMatthewD.Smyth,MD(2008)
Liaison with the American Board of Pediatric Neurological Surgery (ABPNS)TaeSungPark,MD(2010)
Liaison with the Accreditation Council of Pediatric Neurosurgery Fellowships (ACPNF)JeffreyP.Blount,MD(2008)
Liason with ISPNJogiVenkataPattisapu,MD(2010)
Liaison with ASPNRickAbbott,MD(2010-2012)
Liaison with AAP Section of Neurological Surgery (SONS)MarkS.Dias,MD(2009)
Liaison to the Joint Council of State Neurosurgical SocietiesCatherineAnneMazzola,MD(2008)
Liaison to the Coding and Reimbursement Committee, AANSDavidP.Gruber,MD(2010)
Liaison to the Devices and Technology Committee, AANSShenandoahRobinson,MD(2008)
Liaison to the Young Neurosurgeons CommitteeSureshMagge,MD(2012)
Liaison to the Neuro-Critical Care SocietyAshutoshSinghal,MD(2010)
Liaison to Quality/Outcomes GroupsLilianaC.Goumnerova,MD(2010)
AD HOC COMMITTEESEducation Committee Subcommittees (ad hoc)National Meeting SubcommitteeDavidSandberg,MD,Co-Chair(2011-2013)GregOlavarria,MD,Co-Chair(2011-2013)
Communications SubcommitteeAnnM.Ritter,MD,Chair(2009-2012)RichardC.E.Anderson,MD,Website(2009-2012)JeffreyR.Leonard,MD(2008-2010)PeterP.Sun,MD(2008-2010)
Training Subcommittee (Traveling Fellowships and Training)BermansJ.Iskandar,MD,Chair(2010-2012)MatthewD.Smyth,MD(2010-2012)SanjivBhatiaMD,(2010-)DavidI.Sandberg,MD(2010-)
International Education SubcommitteeJogiPattisipu,MD(2010)
Examination Questions CommitteeVacant
Lifetime Achievement AwardAnn-ChristineDuhaime,MD(2009-2012)
Transition of Care CommitteeVacant
Research CommitteeJohnR.W.Kestle,MD,Chair(2007)NalinGupta,MD,PhD(2009)Ann-ChristineDuhaime,MD(2010)EdSmith,MD(2012)
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KEYNOTE SPEAKERS
RosemaryGibsonisanationalleaderinhealthcarequalityandsafetyandaSectionEditoroftheArchives of Internal Medicine“LessisMore”series.Sheisprincipalauthorofthenewbook,The Battle Over Health Care: What Obama’s Health Care Reform Means for America’s Future,anon-partisananalysisofthefuturestateofhealthcareanditsimpactontheeconomy.
RosemarylednationalhealthcarequalityandsafetyinitiativesattheRobertWoodJohnsonFoundationforsixteenyearsinPrinceton,NewJersey.Shewaschiefarchitectofthefoundation’sdecadelongstrategytoestablishpalliativecareinthemainstreamoftheU.S.healthcaresystem.Sheworked withBillMoyersandPublicAffairsTelevisiononthePBSdocumentary,“OnOurOwnTerms,”whichshowedtomorethan20millionviewershowtheU.S.healthcaresystemcanbettercareforseriouslyillpatientsandtheirfamilies.SheinitiatedaseriesintheJournaloftheAmericanMedicalAssociation,“PerspectivesonCareattheCloseofLife.”
Rosemaryisauthorofthecriticallyacclaimedbooks,Wall of Silence,whichtellsthehumanstorybehindtheInstituteofMedicinereport,To Err is Human,andThe Treatment Trap,abookontheoveruseofmedicalcare.HerbookshavebeenreviewedintheJournal of the American Medical Association, Health AffairsandPublishers Weekly,referencedinproceedingsoftheU.S.Senate,mentionedinCongressionaltestimony,notedinThe Wall Street JournalandtheBoston Globe,andhighlightedintheanniversaryissueofO Magazine.
Earlierinhercareer,RosemaryservedasSeniorResearchAssociateattheAmericanEnterpriseInstitute,aWashington,D.C.-basedpublicpolicyorganization;asVicePresidentoftheEconomicandSocialResearchInstitute,apolicythinktank;andasconsultanttotheMedicalCollegeofVirginiaandtheVirginiastatelegislature’sCommissiononHealthCare.ShewasavolunteerandBoardmemberatafreemedicalclinicinWashington,D.C.
RosemaryisagraduateofGeorgetownUniversityandhasamaster’sdegreefromtheLondonSchoolofEconomics.
Dr.Inderisadual-boardedchildneurologistandneonatologist,whodirectsclinicalandtranslationalresearchintothenatureandtimingofbraininjuryinthepretermandhighrisktermborninfant.SheisthedirectoroftheWashingtonUniversityNeonatalDevelopmentResearch(WUNDER)teamandtheWashingtonUniversityIntellectualandDevelopmental
andDisabilitiesResearchCenter(WUIDDRC).
TheWUNDERteamconductsmultidisciplinaryresearchinitiativesinpediatrics,neurology,radiology,obstetrics,andpsychologycenteringbackonstudiesatthebedsideofnewborninfantsintheneonatalandpediatricintensivecareunitatSt.LouisChildren’sHospital.Theteamfocusesoneffortsintheprematureinfant,thesickterminfant,andtheinfantwithcardiacdiseases.Thisresearchutilizesstateofthearttechnologiesinmagneticresonance(MR)imagingandelectroenecephalography(EEG)astoolstoassistinunderstandingthetimingandnatureofbraininjuryinthenewborninfant.
TheWUIDDRCconsistsof4researchcoresinimaging,neuropsychologyandgenetics,animalmodels,biostatisticsandbioinformaticstoaccelerateresearchfindingsininfantsandchildrenbothatriskandwithdevelopmentaldisabilities.ThecenterisfundedbytheNationalInstituteofHealthandsupportsover50investigatorsinadditiontoacentralroleinadvocacyandsupportforchildrenwithdevelopmentaldisabilities.
Finally,Dr.InderholdsaDorisDukeDistinguishedClinicalScientistAwardtoassistherpassioninthementoringofyoungclinicalscientists.
2012 RAIMONDI LECTUREROSEMARY GIBSON, MSc
2012 AAP/SECTION ON NEUROLOGICAL SURGERY (SONS) SPECIAL LECTURETERRIE INDER, MD
LECTURERS
RAIMONDI LECTURERS1978 E.BruceHendrick1979 PaulC.Bucy1980FloydGilles1981PanelDiscussion1982 PanelDiscussion1983 DerekHarwood-Nash1984AnthonyE.GalloJr.1985FrankNulsen1986WilliamF.Meacham1987DaleJohnson1988JosephJ.Volpe1989MartinEichelberger1990GeorgeR.Leopold1991JudahFolkman1992 OlofFlodmark1993 MauricaAlbin1994 BlaiseF.D.Bourgeois1995 RobertH.Pudenz1996SamuelS.Flint1997 M.MichaelCohenJr.1998RobertA.Zimmerman1999DavidB.Schurtleff2000SteveBerman2001AlejandroBerenstein2002VolkerK.H.Sonntag2003JonHuntsman2004J.MichaelBishop2005JamesB.McClintock2006RichardD.Lamm2007RobertoC.Heros2008RenéeJenkins2009CharlesStiles2010RichardC.Karl2011MackBrown2012RosemaryGibson
MATSON MEMORIAL LECTURERS1987 JohnShillito1988 E.BruceHendrick1989 MartinP.Sayers1990 RogerGuillemin1991 RobertL.McLaurin1992 JosephMurray1993 EbenAlexanderJr.1994 JosephRansohoff1995 JohnHolter1996 None1997 MauriceChoux1998 LisaShut1999 GaryC.Schoenwolf2000 Postponedduetoillness2001 DonaldH.Reigel2002 DavidMcLone2003RobinP.Humphreys2004A.LelandAlbright2005JoanL.Venes2006JamesP.McAllister,JamesM.Drake,JosephR.
Madsen,EdwardH.Oldfield2007 HaroldL.Rekate2008 MarionL.Walker2009JohnA.JaneSr.2010JeffreyA.Golden2011ThomasG.Luerssen2012ScottL.Pomeroy
FRANC INGRAHAM AWARDFOR DISTINGUISHED SERVICE AND ACHIEVEMENT RECIPIENTS1988 E.BruceHendrick2001 LuisSchut2004 FredJ.Epstein2007 RobinP.Humphreys2009 DavidG.McLone2010 RobertAlexSanford2011 R.MichaelScott
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1983 Kim ManwaringNeonatalPost-HemorrhagicVentriculomegaly:ManagementwithPulsedLumbarCisternostomy
1984 Arno FriedALaboratoryModelofShunt-DependentHydrocephalus
1985 Ann-Christine DuhaimeTheShakenBabySyndrome
1986 Robert E. BreezeFormationinAcuteVentriculitis
1987 Marc R. DelbigioShunt-InducedReversalofPeriventricularPathologyinExperimentalHydrocephalus
1988 Scott FalciRearSeat-LapBelts.AreTheyReally“Safe”forChildren?
1989 James M. HermanTetheredCordasaCauseofScoliosisinChildrenwithaMyelomeningocele
1990 Christopher D. HeffnerBasilarPonsAttractsitsCorticalInnervationbyChemotropicInductionofCollateralBranchFormation
1991 P. David AdelsonReorganizationoftheCortical-TectalPathwayFollowingNeonatalCerebralHemispherectomyinCats
1992 David FrimEffectsofBiologicallyDeliveredNeurotrophinsinAnimalModelsofNeuralDegeneration
1993 Monica C. WehbyMetabolicDemonstrationofRetainedCNSFunctionintheRabbitModelofInfantileHydrocephalus
1994 Ellen ShaverExperimentalAcuteSubduralHemotomainInfantPiglets
1995 Seyed M. EmadianCorrelationofChromosome17pLosswithClinicalOutcomeinPatientswithPrimitiveNeuroectodermalTumors
1996 John ParkPlateletDerivedGrowthFactorInducesDifferentiationofNeuroepithelialStemCellsintoNeurons
1997 Michael J. DrewekQuantitativeAnalysisoftheToxicityofHumanAmnioticFluidtoRatFetalSpinalCordCultures
1998 Adrianna RangerImplantationofMedulloblastomaCellsintoCollagenTypeIGels:Invasiveness,EnzymaticCharacterization,andtheImpactofSurgicalExcisionandRadiation
1999 Susan DurhamTheSurprisinglySturdyInfantBrain:WhyisitMoreResistanttoFocalInjury?
2000 Ketan R. BulsaraNovelFindingsintheDevelopmentoftheNormalandTetheredFilumTerminale
2001 David I. SandbergConvectionEnhancedDeliveryintotheRatBrainStem:APotentialDeliveryfortheTreatmentofDiffusePontineGliomas
2002 David Cory AdamsonMechanismsofReclosurein2SurgicalModelsofMyelomeningoceleImplicationsforFetalSurgery
2003 Joshua E. MedowPostureIndependentPistonValve:APracticalSolutiontoMaintainingStableIntracranialPressureinShuntedHydrocephalus
2004 Joshua E. MedowThePermiableProximalCatheterProject:ANovelApproachtoPreventingShuntObstruction
2005 David Cory AdamsonDigitalKarotypingIdentifiesaNovelRetinoblastomaOncogene
2006 Elias B. RizkFolateReceptorFunctionisEssentialinCNSRecoveryafterInjury:EvidenceinKnockoutMice
2007 Jeffrey P. GreenfieldAStemCellBasedInfiltrativeModelofPontineGlioma
2008 Toba NiaziMedulloblastomaGrowthEnhancementbyHGF/SFExpressioninCerebellarNeuralProgenitorCellsisSuppressedbySystemicAntibodyTreatment
2009 Symeon MissiosCellProliferationandNeuronalMigrationafterClosedHeadInjuryintheImmaturePiglet
2010 Amanda Muhs SaratsisProteomicAnalysisofCerebralSpinalFluidFromChildrenWithBrainstemGlioma
2011 Paul GiganteEffectsofLumbarSelectiveDorsalRhizotomyonTheUpperExtremetiesinChildren
AWARD RECIPIENTSKENNETHSHULMANAWARDRECIPIENTS
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1989 Eric AltschulerManagementofPersistentVentriculomegalyDuetoAlteredBrainCompliance
1990 Shalom MichowizHighEnergyPhosphateMetabolisminNeonatalHydrocephalus
1991 Nesher G. AsnerVenousSinusOcclusionandVentriculomegalyinCraniectomizedRabbits
1992 Marcia Da SilvaReversalofHighEnergyPhosphateMetabolismChangesinExperimentalHydrocephalusafterCSFShunting
1993 Charles BondurantTheEpidemiologyofCerebrospinalFluidShunting
1994 Monica C. Wehby-GrantTheRabbitModelforInfantileHydrocephalus:RegionalDifferencesintheCorticalMetabolicResponsetoHydrocephalusandShunting
1995 Richard J. FoxCerebrospinalFluidAbsorptiveSiteoftheParasagittalDura:ACadavericStudy
1996 Martha J. JohnsonReactiveAstrocytosisinaNewModelofObstructiveHydrocephalus
1997 No Prize Awarded
1998 Daniel LiebermanInVetroDetectionofFluidFlowinVentriculoperitoncalShunts(VPS)UsingContrastEnhancedUltrasound
1999 Kimberly BingamanHydrocephalusInducestheProliferationofCellsintheSubventricularZone
2000 No Prize Awarded
2001 Jake TimothyTreatmentofHydrocephalusUsingaChoroidPlexusSpecificImmunotoxin:AnInVitroStudy
2002 Joshua MedowQuickBrainMRIvs.CTScanforEvaluatingShuntedHydrocephalus
2002 Jonathan MillerAbberantNeuronalDevelopmentinHydrocephalus
2003 Martin U. SchuhmannSerumandCSFC-ReactiveProteininShuntInfectionManagement
2004 Jeffrey PughCantheSkullDiploicSpaceBeUtilizedforAbsorptionofCerebrospinalFluid?
And
Jay K. Riva-CambrinPediatricPosteriorFossaTumors:Pre-OperativePredictorsofChronicHydrocephalus
2005 Jeffrey P. GreenfieldIntraoperativeAssessmentofThirdVentriculostomySuccess
2006 Kurtis I. AugusteGreatlyImpairedMigrationofAquaporin-4DeficientAstroglialCellsAfterImplantationintoMouseBrain
2007 No Prize Awarded
2008 Ellen L. AirALongutudinalComparisonofPre-andPost-operativeDTIparametesinYoungHydrocephalicChildren
2009 Christopher JansonImmortalizationandFunctionalCharacterizationofRatArachnoidCells
2010 Ramin EskandariEffectsofEarlyAndLateReservoirTreatmentinExperimentalNeonatalHydrocephalus
2011 Ashley Grosvenor TianBilateralHighGradeIntraventricularHemorrhageisAssociatedWithMaleSex,YoungerGestationalAgeAndLowerBirthWeight,ButNotOtherPerinatalFactors
AWARD RECIPIENTSHYDROCEPHALUSASSOCIATIONAWARDRECIPIENTS
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MEETING ROOM FLOOR PLAN
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EXHIBIT HALL FLOOR PLAN
EXHIBITOR LISTING AS OCTOBER 23, 2012
The AANS/CNS Section on Pediatric Neurological Surgery gratefully recognizes the support of the following exhibitors.
Ad-Tech Medical Instrument Corporation1901WilliamStreetRacine,WI53404Phone:(262)634-1555Fax:(262)634-5668www.adtechmedical.comBooth #112
Forover25years,EpilepsyCentershavemadeAd-Techtheirchoiceforinvasiveelectrodesforbrainmappingandepilepsymonitoring.Weofferalargevarietyofelectrodesandaccessoriestomeetyouandyourpatientsneeds.VisitourboothtodiscoverwhyAd-Techisyourbestchoice.
Aesculap, Inc.3773CorporateParkwayCenterValley,PA18034Phone:(610)797-9300Fax:(610)791-6888www.aesculapusa.comBooth #200
Skilledcraftsmanship,qualityandinnovationhavebeenacornerstoneofAesculapformorethan140years.TheAesculapNeurosurgerydivisionprovidesinnovationleadershipincerebrovascular,tumorandhydrocephalustreatments.Aesculapoffersinnovativetechnologiesintheareasofboneremoval,instrumentation,cerebrovascularclips,shunts,neuroendoscopyandcranialfixation.
Biomet Microfixation1520TradeportDriveJacksonville,FL32218Phone:(904)741-4400Fax:(904)741-4500www.biometmicrofixation.comBooth #115
BiometMicrofixationisaleadingmanufactureranddistributorofadvancedcraniomaxillofacialproducts.Biometoffersacompleteportfolioofneurosurgicalreconstructionproductsaimedatimprovingclinicaloutcomes,increasingORefficiencyandenhancingease-of-use.Visitourboothtoviewthelatestinnovations.
BK Medical8CentennialDrivePeabody,MA01960Phone:(978)326-1300Fax:(978)326-1399www.bkmed.comBooth #213
PremiumperformanceneuroimagingfromAnalogic’sBKMedicalultrasoundsystems.Theunparalleledfunctionanddesignofourtwo,newdedicatedneurosurgicaltransducers,combinedwiththeflexFocus800system’sflexibilityandsuperbimagequality,provideneurosurgeonswithauniqueultrasoundimagingsolutiontoaddresstheclinicalchallengestheyfaceeveryday.
Brainlab3WestbrookCorporateCenter,Suite400Westchester,IL60154Phone:(708)409-1343Fax:(708)409-1619www.brainlab.comBooth #102
Brainlabdevelops,manufacturesandmarketssoftware-drivenmedicaltechnologywiththeaimofoptimizingpatienttreatments.Coreproductsrevolvearoundless-invasiveimageguidedsurgerytechnology,moreaccurateandeffectiveradiationtherapy,andintegrationthroughplanningandcollaborationsystemsthatbringspatientdataandphysicianstogether.
Codman, a Johnson & Johnson company325ParamountDriveRaynham,MA02767Phone:(508)880-8100Fax:(508)977-6471www.codman.comBooth #101
Codman,aJohnson&Johnsoncompany,isaglobalneurosciencedevicecompanythatoffersabroadrangeofdevicesandtherapiestotreatpatientswithneurologicaldiseasesandconditions.Thecompany,whichisapartoftheDePuyFranchise,willworkwithhealthcareproviderstoforgeaneweraofinnovationinthecareandtreatmentofthesepatients.MoreinformationonCodmanproductscanbefoundatwww.codman.com.
Domain Surgical1370South2100EastSaltLakeCity,UT84108Phone:(801)924-4950Fax:(801)924-4951www.domainsurgical.comBooth #209
DomainSurgical’sFMwandFerromagneticSurgicalSystemisauniquesurgicaldevicethatharnessesthepowerofferromagneticheatingtosimultaneouslycutandcoagulatesofttissuewhileminimizingcollateraltissuedamage,withoutpassinganelectricalcurrentthroughthepatient.
Hanger Clinic9719OliveBoulevardSt.Louis,MO63146Phone:(314)567-6844Fax:(636)536-3737www.hanger.comBooth #215
Withover600officesnationwideHangerClinicprovidescustomfititemsfromcomplexbracingsystemstospinalandneckorthoticstocranialbands.
Hydrocephalus Association4340EastWestHighway,Suite905Bethesda,MD20814Phone:(888)598-3789Fax:(301)202-3813www.hydroassoc.orgBooth #216
TheHydrocephalusAssociationisanationalnon-profitorganization.Ourmissionistoeliminatethechallengesofhydrocephalusbystimulatinginnovativeresearchandprovidingsupport,educationandadvocacyforindividuals,familiesandprofessionalsdealingwiththecomplexissueofthecondition.TheAssociationprovidescomprehensiveservicesthatempowerindividualsandfamilies.
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EXHIBITOR LISTING AS OCTOBER 23, 2012
IMRIS100-1370SonyPlazaWinnipeg,MBR3T-1N5CanadaPhone:(204)480-7070Fax:(204)480-7071www.imris.comBooth #116
VISIUSSurgicalTheatreisarevolutionary,multifunctionalsurgicalenvironmentthatdeliversunmatchedintraoperativevisiontoclinicianstoassistindecision-makingandenhanceprecisionintreatment.WithintegratedORtechnologies,theVISIUSSurgicalTheatreisoptimizedforintraoperativeimagingwithanMRorCTscannerthattravelstothepatientondemand.
Integra311EnterpriseDrivePlainsboro,NJ08536Phone:(609)275-0500Fax:(609)799-3297www.integralife.comBooth #218
IntegraLifeSciences,aworldleaderinmedicaldevices,isdedicatedtolimitinguncertaintyforsurgeons,sotheycanconcentrateonprovidingthebestpatientcare.Integraoffersavastportfolioofimplants,devices,instrumentsandsystemsusedinneurosurgeryandneurocriticalcare.
KARL STORZ Endoscopy-America, Inc.2151E.GrandAvenueELSegundo,CA90245Phone:(800)421-0837Fax:(424)218-8537www.karlstorz.comBooth #214
KARLSTORZEndoscopy-America,Inc.,aleaderindiagnosticandoperativeendoscopictechnologies,designs,engineers,manufacturesandmarketsproductsemphasizingvisionarydesign,precisioncraftsmanshipandclinicaleffectiveness.KARLSTORZoffersproductsforeverysurgicalspecialty.TheseincludeFULLsolutionsforminimallyinvasiveneurosurgery,frominstrumentationandHDimagingtoORintegration.
KLS MartinPOBox16369Jacksonville,FL32245Phone:(904)641-7746Fax:(904)641-7378www.klsmartin.comBooth #105
KLS-Martinisacompanydedicatedtoprovidinginnovativemedicaldevicesforneurosurgery.Weofferawidevarietyofsurgicalinstruments,titaniumplatesandmesh,customcranialimplants,andtherevolutionarySonicWeldRxsystemforresorbablefixation.CurrentlybasedoutofJacksonville,Florida,wehavehighlyqualifiedrepresentativescoveringtheneedsofsurgeonsthroughoutNorthAmerica.
Kogent Surgical, LLC754GoddardAvenueChesterfield,MO63005Phone:(636)399-7644Fax:(636)787-0603www.kogentneuro.comBooth #211
KogentSurgicaldesignsanddistributesacomprehensivelineofneurosurgicalhandheldtitaniuminstruments,designedwiththehelpofRobertF.Spetzler,MD,andotherluminaryneurosurgeons.Alsoavailableareavarietyofdisposablemalleablesuctiontubes,includinginnovativeilluminatedsuctiontubes.Stopbyourboothtoseemuchmore!
Leica Microsystems1700LeiderLaneBuffaloGrove,IL60089Phone:(847)821-3447Fax:(847)405-2099www.leicamicrosystems.comBooth #204
TheBestjustgotBetter.Designedwithyouinmind,theLeicaMicrosystemsM720OH5neurosurgicalmicroscopewithcompacthorizontalopticsisaparadigmshiftinvision,comfort,andflexibility.SeemorethaneverbeforewithNEWSmallAngleIlluminationandTrueVision®3D–thenextgenerationin3Dteachingtechnology.
Lippincott, Williams and Wilkins/Thieme1019S.ElmAvenueSt.Louis,MO63119Phone:(314)962-8895Fax:(314)962-8895www.lww.comBooth #119
LippincottWilliams&Wilkins,aWoltersKluwerHealthcompanyisaleadinginternationalpublisherofmedicalbooks,journals,andelectronicmedia.Weproudlyofferspecializedpublicationsandsoftwareforphysicians,nurses,studentsandclinicians.Pleasevisitourboothtobrowseourcomprehensiveproductline.
MedTrak10437InnovationDrive,Suite141Milwaukee,WI53226Phone:(414)731-7150Fax:(414)731-7150www.medtrak.coBooth #217
MedTrakprovidespatienthandlingsystemsformulti-modalitysuitesincludingintra-operativeMRI’s,hybridOR’s,MR/ANGIOandimage-guidedradiationtherapysuites.MedTrak’ssystemssimplifythesurgery/imaging/therapytransitions,facilitatingintegrationoftheindependentroomswithinthesuitefortheneurosurgical,neurovascular,cardiovascularandradiationoncologyspecialties.
Medtronic, Inc.710MedtronicParkwayMinneapolis,MN55432Phone:(800)328-2518Fax:(763)505-0450www.medtronic.comBooth #201
AtMedtronic,we’recommittedtoInnovatingforlifebypushingtheboundariesofmedicaltechnologyandchangingthewaytheworldtreatschronicdisease.Todothat,we’rethinkingbeyondproductsandbeyondthestatusquo-tocontinuallyfindmorewaystohelppeoplelivebetter,longer.PleasevisitBooth#201tolearnmore.
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EXHIBITOR LISTING AS OCTOBER 23, 2012
NICO Corporation9190PriorityWayWestDrive,Suite203Indianapolis,IN46240Phone:(317)660-7118Fax:(317)682-0305www.niconeuro.comBooth #219
NICOCorporationisprogressingminimallyinvasivecorridorneurosurgerybycreatinginstrumentsthatallowforsafetumorandcystremovalthroughsmalleropenings.Thisprovidesneurosurgeonsopportunitiesforlessbrainretraction,shortertotalresectiontime,andprecisecontroltoachieveamoreeffectivegrosstotalresection.NICO’sproductsofferthepotentialforlesssurgicaltraumaforpatients,shorterhospitalstays,betterclinicaloutcomes,andimprovedclinicalexperiences.
Piezosurgery Incorporated750CommunicationsParkwayColumbus,OH43214Phone:(614)459-4922Fax:(614)459-4981www.piezosurgery.usBooth #108
Piezosurgery®MedicalbyMectronisanultrasonicsurgicalsystemspecificallydesignedfor:osteotomy,osteoplasty,anddrillinginavarietyofsurgicalapplications.Thedeviceisuniqueasitisdesignedtocutboneandthecuttingactionwillnotcutsofttissuessuchasduramater.
Pro Med Instruments Inc.4529SE16thPlace,Suite101CapeCoral,FL33904Phone:(239)369-2310Fax:(239)369-2370www.headrest.deBooth #104
PMIdesignsandmanufacturesthelargestselectionofcranialstabilizationandbrainretractorsystemsforneurosurgery,includingtheDORO®Multi-PurposeSkullClamp,designedforpediaticapplication.PMIpremiersanewskullclamp,the
Navigation-ReadyDORO®QR3designedforfasterset-up,integratedinterfaces,built-innavigationadaptorandsuperiorstability.Otherinnovations:AutoclavableHeadrestSystemsandFDA-clearedMRI-safeRadiolucentHeadrestSystem.World’sFirstAdjustableNON-STICKBipolarForceps.
RosmanSearch, Inc.30799PinetreeRoad,Suite250PepperPike,OH44124Phone:(216)287-2302Fax:(216)803-6672www.rosmansearch.comBooth #100
RosmanSearchisadual-specialty,trulyexpert,highintegrityneurosurgicalandneurologyrecruitingserviceyoucantrust.Wespecializeexclusivelyinneuropermanentplacement,andourneurosurgicalrecruitmentexpertiseandmethodologyistrulyunique.
Sacred Heart Health Systems5151N9thAvenuePensacola,FL32504Phone:(850)416-1101Fax:(850)416-1147www.sacred-heart.orgBooth #106
SacredHeartHealthSystemisamemberofAscensionHealth,thenation’slargestCatholic,non-profithealthsystem.ThehuboftheHealthSystemisa466-bedacutecarefacilitywhichincludesSacredHeartHospitalinPensacola,SacredHeartChildren’sHospitalandSacredHeartWomen’sHospital.SacredHeartHealthsystemisalsocomprisedofSacredHeartHospitalontheEmeraldCoast,justeastofDestin,FLandSacredHeartHospitalontheGulf,inPortSt.Joe,FL.
Sonowand11660AlpharettaHighway;Suite460Roswell,GA30076Phone:(678)395-6849Fax:(678)615-7610www.sonowand.comBooth #118
SonoWandInviteisaunique,3Dultrasound-basedintraoperativeimagingsystemforneuronavigation.InadditiontoimportingMR/CTimagesforpreoperativeplanning,thesurgeoncanquicklyandeasilygenerateanew3Dnavigationmapthatmoreaccuratelyreflectsthetrueanatomypositionatanytimeduringtheprocedurethuseliminatingtheproblemof“brain-shift.”
Sophysa USA, Inc.303S.MainStreetCrownPoint,IN46307Phone:(219)663-7711Fax:(219)663-7741www.sophysa.comBooth #114
SophysaisfocusedonthedesignandmanufactureofinnovativeCSFManagementtechnologiesandsolutions.Sophysa’spioneeringresearchanddevelopmentcontinuestoexpandthereachoftheglobalneurosurgicalcommunity,focusingonHydrocephalus,andrelateddisordersofCSFdynamics.
Stryker Craniomaxillofacial750TradeCenterWay,Suite200Portage,MI49002Phone:(888)551-6092Fax:(888)551-6092www.stryker.comBooth #110
EXHIBITOR LISTING AS OCTOBER 23, 2012
14
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PROGRAM AT- A- GLANCETIME EVENT LOCATION
6:45AM-7:00PM Registration BallroomFoyer
8:00AM-4:00PM Mid-LevelPractitioner’sSeminar RegencyBallroomAB
9:00AM-4:00PM PracticalClinic:InstrumentationofthePediatricSpine PracticalAnatomy&SurgicalEducationLab(PASE)
6:00-7:30PM OpeningReception GrandHall(lobby)
6:15AM-5:00PM Registration BallroomFoyer
6:45-7:45AM BreakfastSeminar:ContractNegotiationwithHospitalsandInsurers
Illinois/NewYorkCentral
7:15-8:00AM ContinentalBreakfastinExhibitHall GrandBallroom
7:15AM-5:30PM ExhibitHallOpen&E-PosterViewing GrandBallroom
8:00AM-12:00PM Plenary&ScientificSessions RegencyBallroom
9:50-10:15AM BeverageBreakinExhibitHall GrandBallroom
12:00-1:00PM LunchinExhibitHall GrandBallroom
1:00-4:30PM ScientificSessions RegencyBallroom
2:45-3:15PM BeverageBreakinExhibitHall GrandBallroom
4:30-5:30PM Wine/CheeseReceptioninExhibitHall GrandBallroom
6:15AM-5:00PM Registration BallroomFoyer
6:45-7:45AM BreakfastSeminar:PrivatePracticevs.AcademicPediatricNeurosurgery
Illinois/NewYorkCentral
7:15-8:00AM ContinentalBreakfastinExhibitHall GrandBallroom
7:15AM-3:00PM ExhibitHallOpen&E-PosterViewing GrandBallroom
8:00AM-12:00PM Plenary&ScientificSessions RegencyBallroom
9:45-10:15AM BeverageBreakinExhibitHall GrandBallroom
12:00-1:00PM LunchinExhibitHall GrandBallroom
1:00-4:30PM ScientificSessions RegencyBallroom
2:30-3:00PM BeverageBreakinExhibitHall GrandBallroom
4:30-4:45PM AnnualBusinessMeeting RegencyBallroom
4:45-5:30PM MeettheLeadershipReception--ForResidents,FellowsandMedicalStudents
TheDepot
6:00-9:30PM BreweryNight Anheuser-BuschBrewery
6:15AM-11:00AM Registration BallroomFoyer
6:45-7:45AM BreakfastSeminar:ManagingBurnout/StressandUnderstandingQuality/Value
Illinois/NewYorkCentral
7:15-8:00AM ContinentalBreakfastinExhibitHall GrandBallroom
7:15-10:25AM ExhibitHallOpen&E-PosterViewing GrandBallroom
8:00-11:30AM Plenary&ScientificSessions RegencyBallroom
9:55-10:25AM BeverageBreakinExhibitHall GrandBallroom
12:00-4:00PM PracticalClinic:NeuroendoscopyinthePediatricPatient PracticalAnatomy&SurgicalEducationLab(PASE)
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SPEAKER DISCLOSURE INFORMATION
TheAANSandtheAANS/CNSSectiononPediatricNeurologicalSurgerycontrolthecontentandproductionoftheCMEactivityandattempttoensurethepresentationofbalanced,objectiveinformation.InaccordancewiththeStandardsforCommercialSupportestablishedbytheAccreditationCouncilforContinuingMedicalEducation(ACCME),faculty,abstractreviewers,paperpresenters/authors,planningcommitteemembers,staffandanyothersinvolvedinplanningtheeducationalcontentandthesignificantothersofthosementionedmustdiscloseanyrelationshiptheyortheirco-authorshavewithcommercialinterestswhichmayberelatedtotheircontent.TheACCMEdefines“relevantfinancialrelationships”asfinancialrelationshipsinanyamountoccurringwithinthepast12 monthsthatcreateaconflictofinterest.
AsrequiredbytheAmericanNursesCredentialingCenter’sAccreditationProgram,wewouldliketomakeyouawareofallpotentialconflictsofinterest(s).Allspeakershaveagreedtopresentfairlyandwithoutbias.Allsessionswillbemonitoredtoensurethatconflictdoesnotarise.
Relationshipreferstoreceiptofroyalties,consultant,fundingbyresearchgrant,receivinghonorariaforeducationalserviceselsewhere,oranyotherrelationshiptoacommercialinterestthatprovidessufficientreasonfordisclosure.
Thosewhohavedisclosedarelationshipwithcommercialinterestsarelistedbelow:
Samuel R. Browd, MD, PhD Aqueduct Neurosciences, Inc. StockShareholder(Directlypurchased) Echoguide Medical, Inc. StockShareholder(Directlypurchased)
Alexandre Casagrande Canheu, MD SYNTHES OtherFinancialorMaterialSupport
Samuel H. Cheshier, MD, PhD Saint Baldrick’s Foundation Grant/ResearchSupport American Brain Tumor Foundation Discovery Award Grants/ResearchSupport Children’s Health Research Initiative at Stanford Grants/ResearchSupport
Mark S. Dias, MD Allergan Consultants
James M. Drake, MD, MSc, FRCS* MDA Robotics Grant/ResearchSupport L3 Communications Grants/ResearchSupport Phillips Medical Imaging Grants/ResearchSupport Medical Modeling Grants/ResearchSupport
Gerald A. Grant, MD Department of Defense and NIH Grant/ResearchSupport
David F. Jimenez, MD Johnson & Johnson StockShareholder(Directlypurchased)
Sean M. Lew, MD* Medtronic Consultants
David Delmar Limbrick, MD, PhD* NIH/NINDS Grant/ResearchSupport Unpaid consultant, Allied Minds, Inc. Co inventor of device licensed to Allied Minds. Consultants
James P. (Pat) McAllister II, PhD Hydrocephalus Association Grant/ResearchSupport BrainChild Foundation Grants/ResearchSupport University of Utah Department of Neurosurgery Grants/ResearchSupport
Jotham Charles Manwaring, MD Domain Surgical, Inc. Grant/ResearchSupport
Jayant Prasanna Menon, MD Windrose Medical Consultants StockShareholder(Directlypurchased)
Jonathan A. Pindrik, MD The Hartwell Foundation Biomedical Research Fellowship Grant/ResearchSupport
Jose Pineda, MD Integra Neurosciences Honorarium Robert Wood Johnson Foundation Grants/ResearchSupport National Institutes of Health Grants/ResearchSupport
Matthew Jacob Recker DARPA NINDS – for last author ETK only Grant/ResearchSupport Craig Neilsen Foundation – for last author ETK only Grants/ResearchSupport
Jay K. Riva-Cambrin, MD* AANS NREF Fellowship grant 2010 2011, 2011 2012, 2012,2013 Grant/ResearchSupport
Matthew D. Smyth, MD* CURE/DOD Grant/ResearchSupport Novartis Consultants
Mark M. Souweidane, MD Aesculap Consultants
Ato Tafarra Wallace Vanderbilt University Medical Center Grant/ResearchSupport
*Indicatesmemberoftheplanningcommittee
18
SPEAKER DISCLOSURE INFORMATION
Speakers,paperpresenters/authorsandstaff(andthesignificantothersofthosementioned)whohavereportedtheydonothaveanyrelationshipswithcommercialinterests:
Pankaj Kumar Agarwalla, MDAmit Agrawal, MDRaheel Ahmed, MDPhilipp R. Aldana, MDTord D. Alden, MDDaniela Alexandru, MDAnubhav Gautam AminTyler AminaPatty L. Anderson*Richard C. E. Anderson, MD*Kurtis Ian Auguste, MDTyler S. Auschwitz, MDCristina Barrena, MDSanjiv Bhatia, MDJeffrey P. Blount, MDFrederick A. Boop, MD*Ira Eugene BowenDouglas L. Brockmeyer, MDJan Brunstrom Hernandez, MDChristine BuiTene A. Cage, MDMark Calayag, MDKevin CarrVikram ChakravarthyParthasarathi Chamiraju, MDKevin Z. J. Chao, MDSue Christiansen*Aaron John Clark, MDDavid Douglas Cochrane, MDAlan R. Cohen, MD*Daniel J. Curry, MDStephanie Louise Da SilvaLawrence Blevin Daniels III, MDLaurence Davidson, MDMichael George DeCuypere, MDSohum K. Desai, MDMichael DiLuna, MDMichael S. B. Edwards, MDSamer K. Elbabaa, MDAria Fallah, MDAnn Marie Flannery, MDKimberly Anne Foster, MDDavid M. Frim, MD, PhD*Fabio FrisoliSarah Tamara Garber, MDMatthew Frank Gary, MDSara GhayouriRahel GhenbotTrina GhoshRosemary Gibson, MSc
Jakub GodzikLiliana C. Goumnerova, MDPaul A. Grabb, MDDavid P. Gruber, MDTodd Cameron Hankinson, MD, MBADevon H. Haydon, MDYizheng HeCaitlin Elizabeth Hoffman, MDAbby Hollander, MDSteven W. Hwang, MDGeorge M. Ibrahim, MDTakayuki Inagaki, MDTerrie Inder, MDSantoshi Shalini IndrakantiBermans J. Iskandar, MDAndrew Jea, MDYasser Jeelani, MDSarah C. Jernigan, MDJames M. Johnston Jr., MDPamela Stuart Jones, MDShejoy P. Joshua, MDJothy Kandasamy, MBBS BScBruce A. Kaufman, MDColin John Kazina, BSc, MD, BSc(Med),
FRCSCMeysam Ali Kebriaei, MDJoseph Ryan Keen, DOBrian Joseph Kelley, MDChristopher Paul Kellner, MDAmy KilleenPaul Klimo Jr., MDMatthew KoleLibby Marie Kosnik-Infinger, MD, MPHAbhaya Vivek Kulkarni, MDApril Kutheis, RN*Shih Shan Lang, MDAmy Lee, MDBrian Lee, MDJeffrey R. Leonard, MD*Julian J. Lin, MDVictor Liu, BSSubash Lohani, MDSamantha A. Luebbering*Cormac O. Maher, MDFrancesco T. Mangano, DONeena Ishwari Marupudi, MDCatherine Anne Mazzola, MD*Brian Jeffrey McHugh, MDRobert Moore, MDAnthony MyintMustafa Moh’D Y. Nadi, MDRobert Partlow Naftel, MDIfeanyi David NwokeabiaW. Jerry Oakes, MDSacit Bulent Omay, MDBrent Randle O’Neill, MD
Lauren Rose Ostling, MDTimothy Ryan OwensTae Sung Park, MDRobert Paschall, MDJoseph H. Piatt Jr., MDIan F. Pollack, MD*Alexander K. Powers, MDMark R. Proctor, MD*Rabia Qaiser, MDJohn Ragheb, MD*Prajwal Rajappa, MDVikas Y. Rao, MDGaddum Reddy, MD, PhDRenee M. Reynolds, MDElias B. Rizk, MDAdetola O. Roberts, MDShenandoah Robinson, MDBrandon G. Rocque, MDKristen Leigh SaligaAdam Lance Sandler, MDAmanda Muhs Saratsis, MDJennifer Gentry Savage, MDChristina Mieko Sayama, MDSteven J. Schiff, MD, PhDNathan R. Selden, MD, PhDCesar Augusto Serrano Almeida, MDChevis Shannon, DrPHJosh Shimony, MDSheila Kumari Singh, MDAshutosh Singhal, MDEdward Robert Smith, MDHeather Stevens Spader, MDJennifer Mae Strahle, MDKieron SweeneyAndrei B. Talanov, MD, PhDMichael D. Taylor, MD, PhDEric Michael Thompson, MDLuke Tomycz, MDZulma Sarah Tovar Spinoza, MDGerald F. Tuite Jr., MDRachana Tyagi, MDElizabeth C. Tyler-Kabara, MD, PhDShobhan H. Vachhrajani, MDSudhakar Vadivelu, DOMark Daniel Van Poppel, MDE. Haley Vance, MSNTimothy W. Vogel, MDJoanna Wang, BSJohn C. Wellons III, MD*Nicholas M. Wetjen, MDWilliam E. Whitehead, MD, MPHRicky H. Wong, MDChester Kossman Yarbrough, MDScott Zuckerman, MD
*Indicatesmemberoftheplanningcommittee
SPEAKER DISCLOSURE INFORMATION
19
MID-LEVEL PRACTITIONER’S SEMINAR
TUESDAY, NOVEMBER 27
8:00AM–4:00PMRegencyBallroomAB
ThegoaloftheMid-LevelPractitioner’sSeminaristoaddressthechallengesofmultidisciplinaryapproachesandneurosurgicalcareinoutpatientsettings.Thisseminarwillprovidepresentationsfromanumberofperspectivesaddressingpediatrictraumaandcriticalcare,neuroanatomyandneurosurgicaldisordertopics.Tosuccessfullycompletethiscourse,youmustbeinattendancefortheentireeventandsubmitacompletedcourseevaluationattheconclusionoftheevent.Lunchisprovided.
Learning Ojectives: Describetheappropriateoutpatientevaluationforlesions
likelytoaffectthehypothalamicpituitaryaxis Describethecurrentstate-of-the-fieldfortheevaluationand
treatmentofspasticityrelatedtocerebralpalsy Describediagnostictechniquesfornon-accidentaltrauma
andresourcestofacilitatecare Differentiatesurgicalandnon-surgicalcausesofabnormal
headshape. Reviewstate-of-the-artoutpatientevaluationmethodsfor
commonneurosurgicalproblems Discusstechnicalconsiderationsforthetreatmentof
hydrocephalus Recognizetheemergenceofmultidisciplinaryapproachesto
treatmentoftraumaticbraininjury Recognizetheimpactofmultidisciplinaryapproacheson
patientcare Constructmanagementplansforpatientswithtraumatic
cervicalinjuries ConstructmanagementplansforpatientswithICPmonitors,
EVDsandshunts Recognizetheroleofevidence-basednursedrivenresearch
inpediatricneurosurgery ExplainandapplyemergingMRItollsfortheevaluationof
neurosurgicalconditions
8:00–8:15AMWelcome And IntroductionDavidDelmarLimbrick,MD,PhD
8:15–8:45AMEndocrine Evaluation of Sellar And Suprasellar LesionsAbbyHollander,MD
8:45–9:15AMMultimodal Approaches For Cerebral PalsyJanBrunstrom-Hernandez,MD
9:15–9:45AMImproving Care of The Child With Spina Bifida: The Multidisciplinary ApproachPhilippR.Aldana,MD
9:45–10:15AMEvidence-Based Practice: The Influence And Impact of Nursing ResearchChevisShannon,DrPHE.HaleyVance,MSN,CPNP
10:15–10:30AMBeverage Break
10:30–11:00AMVascular Abnormalities in The Infant And ChildEdwardRobertSmith,MD
11:00–11:30AMEvaluating Infant Head Shape: Operative And Non-Operative CasesAmyLee,MD
11:30AM–12:00PMTechnical Considerations in Hydrocephalus Treatment: Hardware Choice And EndoscopyDavidDelmarLimbrick,MD,PhD
12:00–1:00PMLunch
1:00–1:30PMNon-Accidental Trauma: Medical And Social IssuesRobertPaschall,MD
1:30–2:00PMCervical Spine Injuries: Minor to MajorJeffreyR.Leonard,MD
2:00–2:30PMTroubleshooting EVDs And ICP MonitorsTimothyW.Vogel,MD
2:30–3:00PMCritical Care Issues in The Management of The Child With Traumatic Brain InjuryJosePineda,MD
3:00–3:15PMBeverage Break
3:15–4:00PMMRI Fundamentals For The Brain And SpineJoshShimony,MD
20
PROGRAM SCHEDULE
TUESDAY, NOVEMBER 27
6:45AM–7:00PMRegistrationBallroomFoyer
7:00–11:00AMABPNS Board MeetingMissouri/Pacific
8:00AM–4:00PMMid-Level Practitioner’s SeminarRegencyBallroomAB
PRACTICAL CLINICInstrumentation of the Pediatric SpinePracticalAnatomy&SurgicalEducationLab(PASE)
9:00AM–4:00PMTransportation,ContinentalBreakfastandLunchincluded.Bustodepartfromhotelat8:30AM
Thepurposeofthiscoursewillbetopresentanoverviewofinstrumentationofthepediatricspine.Handsonworkshopswillallowparticipantstopracticecranialjunctioninstrumentation,lateralmassscrew,anteriorcorpectomiesandplatingandpediclescrewplacementforbothdeformityandtrauma.Thecoursewillalsobeflexibletoallowparticipantstofocusonparticularareasofinterestinpediatricspine.
FacultyRichardC.E.Anderson,MDDouglasL.Brockmeyer,MDJamesM.JohnstonJr.,MDAlexanderK.Powers,MD
Attendeeswillreceiveamaximumof6.5AMA PRA Category 1 CreditsTMforthispracticalclinic.
12:00–5:00PMExecutive Committee MeetingIllinois/NewYorkCentral
4:00–6:00PMSpeaker Ready RoomTheDepotRoom
5:00–5:30PMEducation CommitteeIllinois/NewYorkCentral
6:00–7:30PMOpening ReceptionGrandHall(lobby)Dressisbusinessattire
WEDNESDAY, NOVEMBER 28
6:15AM–5:00PMRegistrationBallroomFoyer
6:45–7:45AMBreakfast Seminar: Contract Negotiation with Hospitals and InsurersIllinois/NewYorkCentralRooms
Presenterswilldiscusshowtokeeptheupperhandwhennegotiatingwithhospitaladministratorsaswellasprovidingadviceonhowtobeanadvocateforyourpatientswhennegotiatingwithinsurancecompaniesandotherpayers.
PanelistsFrederickA.Boop,MDDavidF.Jimenez,MD
Attendeeswillreceiveamaximumof1AMA PRA Category 1 CreditsTMforeachBreakfastSeminar.
7:00AM–4:00PMSpeaker Ready RoomTheDepotRoom
7:15–8:00AMContinental Breakfast in Exhibit HallGrandBallroom
7:15AM–5:30PMExhibit Hall Open & E-Poster ViewingGrandBallroom
8:00–8:05AMWelcome and Opening RemarksRegencyBallroomAlanR.Cohen,MD
21
PROGRAM SCHEDULE
PleaseNote:AllHydrocephalusandShulmanAwardCandidatesareindicatedwith**
8:05–9:05AM
SCIENTIFIC SESSION I – SAFETY, QUALITY & OUTCOMESModeratorsCatherineAnneMazzola,MDMarkR.Proctor,MD
8:05–8:13AM1. Evaluating Infection Trends in Pediatric Neurosurgical Patients: A Multidisciplinary Process Improvement InitiativeChevisShannon,DrPH;KyleAune;StevenVeselsky;AnastasiaArynchyna;AmitaBey;JohnWellons,MD,MPH(Birmingham,AL)
8:13–8:21AM2. Establishing ImPACT Norms For The Learning Disabled Following Sports-Related Concussion: A Neglected PopulationScottZuckerman,MD;YoungLee,BS;MitchellOdom,BS;GarySolomon,PhD;AllenSills,MD(Nashville,TN)
8:21–8:29AM3. Establishment of a Multidisciplinary Concussion Program: Impact of Standardization on Patient Care And Resource UtilizationJamesM.JohnstonJr.,MD;StevenBrown,BA;SaraWilkins,BA;MichaelFalola,MD,MPH;MarshallCrowther,MD;KimberlyGran,MD;ChevisShannon,PhD(Birmingham,AL)
8:29–8:37AM4. Review of Complications After Elective Craniotomy: Does my Patient Need to go to The ICU?AshutoshSinghal,MD,FRCSC;JohnKerr,BS(Vancouver,Canada)
8:37–8:45AM5. Detectibility of Implanted Neuropatties on Intra-Operative Radiographs Assessed in a Cadaver ModelDavidDouglasCochrane,MD;ThomasLou,BS;JohnMawson,MD;RobertAlmack;ApryilNoga(Vancouver,Canada)
8:45–8:53AM6. A Comparison of Costs Associated With Endoscope-Assisted Craniectomy Vs. Open Cranial Vault Repair For Infants With Sagittal SynostosisTimothyW.Vogel,MD;AlbertWoo,MD;AlexKane,MD;KamleshPatel,MD;SybillNaidoo,NP;MatthewSmyth,MD(St.Louis,MO)
8:53–9:01AM7. Creating Evidence-Based Recommendations For The Treatment of Children With HydrocephalusAnnMarieFlannery,MD;CatherineMazzola,MD;PaulKlimo,MD;BenjaminWarf,MD;MandeepTamber,MD;JayRivas-Cambrin,MD;DavidLimbrick,MD;JoannaKemp,MD;AsimChoudhri,MD;TinaDuhaime,MD;LissaBaird,MD;DimitiosNikas,MD;KurtAuguste;MarkVanPoppel,MD;LauraRaymond(St.Louis,MO)
9:01–9:05AM8. Pedsneurosurgery.org: A New BeginningRichardC.E.Anderson,MD;JeffreyLeonard,MD;AnnRitter,MD(NewYork,NY)
9:05–9:50AMClinical Symposia: Surgical Treatment of Spasticity
ModeratorAlanR.Cohen,MD
PanelistsBruceA.Kaufman,MDTaeSungPark,MD
9:50–10:15AMBeverage Break in Exhibit HallGrandBallroom
10:15–11:11AM
SCIENTIFIC SESSION II – FUNCTIONAL/SPASTICITYModeratorsPhilippR.Aldana,MDElizabethC.Tyler-Kabara,MD,PhD
10:15–10:23AM9. Occipital Nerve Decompression Improves Peds QOL Scores in Chronic Daily Headache**SohumK.Desai,MD;SudhakarVadivelu,DO;GabrielBrooks,PhD;DeannaDuggan;RobertDauser,MD;AndrewJea,MD;WilliamWhitehead,MD;ThomasLuerssen,MD;RobertBollo,MD;DianaLebron,MD;DanielCurry,MD(Galveston,TX)
10:23–10:31AM10. The Impact of a Novel Analgesia Protocol on Children Undergoing Selective Dorsal RhizotomyRobertMoore,MD;CharlesSchrock,MD;RaniSunder, MD;TracyWester,MD;KatherineKeech,MD;JamesSerot,MD;SoniaShahrawat,MD;SydneyNykiel,DO;T.Park,MD(St. Louis,MO)
22
PROGRAM SCHEDULE
10:31–10:39AM11. Risk Factors For Baclofen Pump Infections: A Multivariate Analysis**HeatherStevensSpader,MD;RobertBollo,MD;JudyGooch,MD;MarionWalker,MD;JayRiva-Cambrin,MD(Providence,RI)
10:39–10:47AM12. Deep Brain Stimulation to Treat Dystonia in a Transgenic Mouse Model of Rett Syndrome: Technical DescriptionDanielJ.Curry,MD;AkashPatel,MD;JianrongTang,MD;ZhengyuWu;JavierMata,MD;HudaZoghbi,MD;KirstenUre,PhD(Houston,TX)
10:47–10:55AM13. Effect of Deep Brain Stimulation on Dystonic Cerebral Palsy in ChildrenJosephRyanKeen,DO;AllisonPrzekop,DO;JoffreOlaya,MD;FrankHsu,MD,PhD;AlexanderZouros,MD(Loma Linda,CA)
10:55–11:03AM14. Impact of Hydrocephalus, Birth Weight, And Epilepsy on Intellectual Ability in Cerebral Palsy**MeysamAliKebriaei,MD;AnaArenivas,PhD;MatthewGary,MD;KentrellBurks,MD;DonaldBearden,MS;ThomasBurns,PhD;JoshuaChern,MD,PhD(Atlanta,GA)
11:03–11:11AM15. Attempted Bladder Reinnervation in Spinal Cord Injury: Clinical, Electrophysiologic And Histologic Outcome After The Xiao ProcedureGeraldF.TuiteJr.,MD;BruceStorrs,MD;YvesHomsy,MD;SarahGaskill,MD;EthanPolsky,MD;MargaretReilly, BS;StevenWinesett,MD;LuisRodriguez,MD;CarolynCarey,MD;SharonPerlman,MD;LisaTetreault,RN(St. Petersburg, FL)
11:11AM–12:00PMRAIMONDI LECTURERosemaryGibson,MScWhere Are We Headed: Health Care And America’s Economic Future
12:00–1:00PMLunch in Exhibit HallGrandBallroom
1:00–2:20PM
SCIENTIFIC SESSION III – EPILEPSYModeratorsFrederickA.Boop,MDNicholasM.Wetjen,MD
1:00–1:08PM16. Disruption of Rolandic Gamma-Band Functional Connectivity by Seizures is Associated With Motor Impairments in Children With Epilepsy**GeorgeM.Ibrahim,MD;TomoyukiAkiyama,MD,PhD;AyakoOchi,MD,PhD;HiroshiOtsubo,MD;MaryLouSmith,PhD;MargotTaylor,PhD;ElizabethDonner,MD;JamesRutka,MD,PhD;O.CarterSnead,MD;SamDoesburg,PhD(Toronto,Canada)
1:08–1:16PM17. Volumetric CT Analysis as a Predictor of Seizure Outcome Following Temporal LobectomyStevenJ.Schiff,MD,PhD;JasonMandell,MS;KennethHill,MD;DanNguyen,MD;KevinMoser,MD;RobertHarbaugh,MD;JamesMcInerney,MD;BryanKaaya;DerekJohnson,BS;WarrenBoling,MD;BenjaminWarf,MD;AndrewWebb,PhD(UniversityPark,PA)
1:16–1:24PM18. Seizure Outcomes Following Stereoelectroencephalography-Guided Resective Epilepsy Surgery in Children: A Longitudinal AnalysisAriaFallah,MD;GeorgeIbrahim,MD;SumeetVadera, MD;JeffreyMullin,MD;JorgeGonzalez-Martinez, MD,PhD(Toronto,Canada)
1:24–1:32PM19. Surgical Outcome And Prognostic Factors in Children With Medically Intractable Epilepsy Caused by Focal Cortical DysplasiaBrentRandleO’Neill,MD;AndrewWhite,MD;PramoteLaoprasert,MD;MichaelHandler,MD(Aurora,CO)
1:32–1:40PM20. Navigating Eloquent Cortex: Combined Utility of Neuroimaging, Neuromonitoring And Cortical Mapping in Rolandic Epilepsy SurgeryMustafaMoh’DY.Nadi,MD;GeorgeIbrahim,MD;SamuelStrantzas;ElizabethPang;JamesDrake,MD,MSC;JamesRutka,MD,PhD(Toronto,Canada)
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PROGRAM SCHEDULE
1:40–1:48PM21. Surgery For Intractable Epilepsy Due to Unilateral Brain Disease: A Retrospective Study Comparing Hemispherectomy TechniquesSubashLohani,MD;AnnaPinto,MD;AnnBergin,MD;BlaiseBourgeois,MD;PeterBlack;SanjayPrabhu,MD;JosephMadsen,MD;MasanoriTakeoka,MD;AnnapurnaPoduri(Boston,MA)
1:48–1:56PM22. MRI Guided Stereotactic Laser Thermal Ablation Technique in Epilepsy Surgery Our Initial ExperienceParthasarathiChamiraju,MD;SanjivBhatia,MD;JohnRagheb,MD;SantiagoMedina,MD,MPH;NolanAltman, MD;EsperanzaPacheco,MD;IanMiller,MD(Miami,FL)
1:56–2:04PM23. Predictors of Seizure Outcomes in Children With Tuberous Sclerosis Complex And Intractable Epilepsy Undergoing Resective Epilepsy Surgery: An Individual Participant Data Meta-Analysis**AriaFallah,MD;GordonGuyatt,MD,MSC;O.CarterSneadIII,MD;ShanilEbrahim;GeorgeIbrahim,MD;AlirezaMansouri,MD;DevenReddy,MD;StephenWalter, PhD;AbhayaKulkarni,MD,PhD;MohitBhandari, MD,PhD;LauraBanfield,MS;NeeraBhatnagar;ShuliLiang,MD,PhD;FedericaTeutonico,MD;JianxiangLiao,MD,PhD;JamesRutka,MD,PhD(Toronto,Canada)
2:04–2:12PM24. From Two Surgeries to One: Advanced Neuroimaging Reduces Invasive Monitoring in Pediatric Epilepsy SurgeryPankajKumarAgarwalla,MD;ElizabethThiele, MD, PhD;RonaldThibert,MD;CatherineChu-Shore,MD;BradleyBuchbinder,MD;StevenStufflebeam,MD;PaulCaruso, MD;MirelaSimon,MD;Ann-ChristineDuhaime, MD(Boston,MA)
2:12–2:20PM25. Functional Lesionectomy: A Minimally Resective Strategy Effective in Children With MRI-Negative, Intractable EpilepsyJohnRagheb,MD;SanjivBhatia,MD;AnnHyslop,MD;IanMiller,MD;PrasannaJayakar,MD(Miami,FL)
2:20–2:45PMQI/NSQIP/NPA UpdateLilianaC.Goumnerova,MD
2:45–3:15PMBeverage Break in Exhibit HallGrandBallroom
3:15–4:27PMSCIENTIFIC SESSION IV – VASCULAR/CRANIOSYNOSTOSISModeratorsJamesM.JohnstonJr.,MDEdwardRobertSmith,MD
3:15–3:23PM26. Calvarial Thickness And Diploic Space Development in Children With Sagittal Synostosis Assessed by Computed TomographyTrinaGhosh;GarySkolnick,BA;HankSun,BA;KamleshPatel,MD;MatthewSmyth,MD;AlbertWoo,MD(Kansas City,MO)
3:23–3:31PM27. Less-Invasive Pedicled Omental-Cranial Transposition in Pediatric Patients With Moyamoya Disease And Failed Prior RevascularizationKevinZ.J.Chao,MD;RamonNavarro,MD;PeterGooderham,MD;MatiasBruzoni,MD;SanjeevDutta,MD;GarySteinberg,MD,PhD(PaloAlto,CA)
3:31–3:39PM28. Intra And Inter-Rater Reliability of The Pediatric AVM Compactness ScoreFabioFrisoli;Shih-ShanLang,MD;ArastooVossough, MD, PhD;AnneMarieCahill,MD;HishamDahmoush,MD;GregoryHeuer,MD,PhD;PhillipStorm, MD;LaurenBeslow,MD(Philadelphia,PA)
3:39–3:47PM29. Skull Growth and Cranial Vault Volumes in Sagittal SynostosisRahelGhenbot;GarySkolnick,BS;KamleshPatel,MD;SybillNaidoo,NP;MatthewSmyth,MD;AlbertWoo,MD
3:47–3:55PM30. Anterior Fontanelle Size And Closure in Full Term Children Based on Head Computed Tomography**JonathanA.Pindrik,MD;BoramJi,BS;CourtneyPendleton, MD;EdwardAhn,MD(Baltimore,MD)
3:55–4:03PM31. Pediatric Moya-Moya: Surgical Variation, Seizure Outcomes, And Angiographic Followup**LukeTomycz,MD;AtoWallace,BS;LailaHaasan-Malani;PeterMorone,MD;RobertSinger,MD;RobertMericle,MD(Nashville,TN)
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4:03–4:11PM32. Features of Cerebral Arteriovenous Malformations in ChildrenAndreiB.Talanov,MD,PhD(Ivanovo,RussianFederation)
4:11–4:19PM33. Multi-Concentric Osteotomy For Correction of Cranial Deformities: Case Series And Follow-upJenniferGentrySavage,MD;MicamTullous,MD;PatriciaMancuso,MD(SanAntonio,TX)
4:19–4:27PM34. The Safety of The Intraoperative Sacrifice of The Deep Cerebral VeinsJ.McComb,MD;LaurenceDavidson,MD(NationalNavalMedicalCtr,MD)
4:27–4:30PMAnnouncements
4:30–5:30PMWine and Cheese Reception in Exhibit HallGrandBallroom
THURSDAY, NOVEMBER 29
6:15AM–5:00PMRegistrationBallroomFoyer
6:45–7:45AMBreakfast Seminar: Private Practice vs. Academic Pediatric NeurosurgeryIllinois/NewYorkCentralRooms
Developingasuccessfulprivatepracticeinpediatricneurologicalsurgeryischallenging…butpossible.Buildingasuccessfulacademiccareerinpediatricneurologicalsurgeryrequiresdifferentstrategies.Comeandfindoutanswerstoyourquestions.
PanelistsCatherineAnneMazzola,MDNathanR.Selden,MD,PhD
Attendeeswillreceiveamaximumof1AMA PRA Category 1 CreditsTMforeachBreakfastSeminar.
7:00AM–4:00PMSpeaker Ready RoomTheDepot
7:15–8:00AMContinental Breakfast in Exhibit HallGrandBallroom
7:15AM–3:00PMExhibit Hall Open & E-Poster ViewingGrandBallroom
8:00–8:05AMAnnouncementsRegencyBallroom
8:05–9:09AMSCIENTIFIC SESSION V – NEOPLASM IModeratorsSamuelR.Browd,MD,PhDGeraldA.Grant,MD
8:05–8:13AM35. Protein Profiling of Diffuse Intrinsic Pontine Glioma Tumor Tissue: A Comparative Analysis**AmandaMuhsSaratsis,MD;KendallSnyder;JordanHall;MadhuriKambhampati;SrideviYadavilli,PhD;JenniferPerez,BA;SureshMagge,MD;JavadNazarian,PhD(Arlington,VA)
8:13–8:21AM36. BRAF-Targeted Therapeutics in Low-Grade Gliomas**Shih-ShanLang,MD;AngelaSievert,MD,MPH;KatieBoucher,BS;PhillipStorm,MD;AdamResnick,PhD(Philadelphia,PA)
8:21–8:29AM37. Neo-Adjuvant Chemotherapy Improves Survival for Infants With Ependymoma: Preliminary Results of St. Jude Young Children (SJYC07) TrialFrederickA.Boop,MD;PaulKlimo,MD,MPH;KarenWright,MD;AmarGajjar,MD;T.Hassall,MD;DBowers, MD;J.Crawford,MD;AtmanPai,MD;ThomasMerchant,DO;DavidEllison,MD;FrederickBoop,MD(Memphis,TN)
8:29–8:37AM38. Role of Bone Marrow Derived Cells in The Tumor Microenvironment of Medulloblastoma**CaitlinElizabethHoffman,MD;KarenBadal,MD;PrajwalRajappa,MD;YujieHuang,PhD;JacquelineBromberg, MD,PhD;DavidLyden,MD,PhD;JeffreyGreenfield,MD,PhD(NewYork,NY)
8:37–8:45AM39. Pseudoprogression of Low Grade Gliomas After RadiotherapyRobertPartlowNaftel,MD;MelvinDeutsch,MD;ReginaJakacki,MD;IanPollack,MD(Pittsburgh,PA)
PROGRAM SCHEDULE
WITHDRAWN
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PROGRAM SCHEDULE
8:45–8:53AM40. Systematic Review of The Results of Surgery And Radiotherapy on Tumor Control For Pediatric Craniopharyngioma**AaronJohnClark,MD;TeneCage,MD;DerickAranda, MD;AndrewParsa,MD,PhD;PeterSun, MD;KurtisAuguste,MD;NalinGupta,MD,PhD(San Francisco, CA)
8:53–9:01AM41. Effect of Surgical Debulking on Post-Operative Cerebellar MutismAnthonyMyint;YasserJeelani,MD;JessicaAshford,MS;StephanieDaSilva,BA;J.GordonMcComb,MD;MarkKrieger,MD(SanMarino,CA)
9:01–9:09AM42. Fluorescence-Guided Resection of Pediatric CNS Neoplasms With The Use of Novel, Saposin C-Dioleoylphosphatidylserine (Sapc-DOPS) NanovesiclesLaurenRoseOstling,MD;XiaoyangQi,PhD;CharlesStevenson,MD(Cincinnati,OH)
9:09–9:54AMClinical Symposia: Update on Malignant Pediatric Bain Tumors
ModeratorJeffreyR.Leonard,MD
PanelistsIanF.Pollack,MDMichaelD.Taylor,MD,PhD
9:54–10:15AMBeverage Break in Exhibit HallGrandBallroom
10:15–11:11AMSCIENTIFIC SESSION VI – NEOPLASM IIModeratorsToddCameronHankinson,MD,MBAIanF.Pollack,MD
10:15–10:23AM43. Progression of Craniopharyngioma Following Conformal RadiationPaulKlimoJr.,MD;FrederickBoop,MD;KyleGabrick,BS;ThomasMerchant,MD;RobertSanford,MD(Memphis,TN)
10:23–10:31AM44. Evaluation of a New Staging System For Juvenile Nasopharyngeal Angiofibromas (JNA)KimberlyAnneFoster,MD;CarlSnyderman,MD;EricWang,MD;CarlosPinheiro,MD;H.Pant,MD;JuanFernandez-Miranda,MD;PaulGardner,MD;ElizabethTyler-Kabara,MD,PhD(Pittsburgh,PA)
10:31–10:39AM45. Decision Analysis of Treatment Options For Pediatric CraniopharyngiomasLawrenceDaniels,MD;ZarinaS.Ali,MD;RobertBailey, MD;JohnLee,MD;PhillipStorm,MD;ShermanStein,MD;GregoryHeuer,MD,PhD(Philadelphia,PA)
10:39–10:47AM46. Pseudoprogression in The Pediatric Brain Tumors**ChesterKossmanYarbrough,MD;AravindSomasundaram,BS;JeffreyLeonard,MD(St.Louis,MO)
10:47–10:55AM47. Does The Presence or Development of Hydrocephalus Affect The Prognosis For Diffuse Intrinsic Pontine Glioma?IfeanyiDavidNwokeabia;JohnGrimm,MD;IraBowen, BA;YasserJeelani,MD;SaraGhayouri;StephanieDaSilva,MD;MarkKrieger,MD;J.GordonMcComb,MD(Washington,DC)
10:55–11:03AM48. Morbidity And Neurological Outcomes Following Repeat Surgical Resection of Pediatric Intramedullary Tumors**RaheelAhmed,MD;ArnoldMenezes,MD(IowaCity,IA)
11:03–11:11AM49. Greater Extent of Resection Improves Progression-Free Survival in Children With Gangliogliomas: A Volumetric AnalysisDevonH.Haydon,MD;JeffreyLeonard,MD(St. Louis, MO)
11:11AM–12:00PMAAP/SECTION ON NEUROLOGICAL SURGERY (SONS) SPECIAL LECTURE TerrieE.Inder,MDAdvances in Improving Outcomes in the Newborn Brain
12:00–1:00PMLunch in Exhibit HallGrandBallroom
1:00–1:10PMSmall Grant Research AwardsMarkM.Souweidane,MDGeraldF.TuiteJr.,MD
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PROGRAM SCHEDULE
1:10–2:30PMSCIENTIFIC SESSION VII – HYDROCEPHALUS I ModeratorsBermansJ.Iskandar,MDFrancescoT.Mangano,DO
1:10–1:18PM50. Quality Measures For The Management of Hydrocephalus: Concepts, Simulations, And Preliminary Field TestingJosephH.PiattJr.,MD;SpencerBarton;JeffreyCampbell, MD(MerionStation,PA)
1:18–1:26PM51. Fourth Ventricular Shunt Survival Comparing Parietal Stereotactic Endoscopic Transtentorial And Suboccipital Approaches**SarahTamaraGarber,MD;FrankBishop,MD;DouglasBrockmeyer,MD;JayRiva-Cambrin,MD(SaltLakeCity,UT)
1:26–1:34PM52. Ventriculomegaly Diagnosed on Fetal MRI And The Risk of Post-Natal HydrocephalusMatthewKole;JenniferWilliams,MD;AngelKrueger;DeboraYbarra;WilliamWhitehead,MD;ChristopherCassady,MD;RobertBollo,MD(Houston,TX)
1:34–1:42PM53. Abnormal Development of NG2+PDGFRα+ Neural Progenitor Cells Causes Neonatal HydrocephalusTimothyW.Vogel,MD;CalvinCarter,BA;QihongZhang, PhD;TomMoninger,PhD;DanThedens,PhD;KimberlyKeppler-Noreuil,MD,PhD;DarrylNishimura,PhD;CharlesSearby,PhD;KevinBugge,BA;ArnoldMenezes, MD;ValSheffield,MD,PhD(St.Louis,MO)
1:42–1:50PM54. Decorin Reduces Ventriculomegaly And Subarachnoid Fibrosis in Juvenile Rats With Communicating HydrocephalusJamesP.(Pat)McAllisterII,PhD;HannahBotfield,MS;AndersSkjolding,MD;AnaGonzalez,PhD;OsamaAbdullah,MS;MartinBerry,PhD;AnnLogan,PhD(SaltLakeCity,UT)
1:50–1:58PM55. Frontal Versus Parietal CSF Shunts And Shunt Survival, an HCRN StudyWilliamE.Whitehead,MD,MPH;AbhayaKulkarni, MD;JayRiva-Cambrin,MD;JohnWellons,MD;JamesDrake, MD;ThomasLuerssen,MD;JerryOakes,MD;MarionWalker,MD;JohnKestle,MD(Houston,TX)
1:58–2:06PM56. The Risk Factors For And The Influence of Hydrocephalus on Neurological Outcome in Children Born With an EncephaloceleStephanieLouiseDaSilva;YasserJeelani,MD;AndrewYousef;MarkKrieger,MD;J.GordonMcComb,MD(LosAngeles,CA)
2:06–2:14PM57. Limited Sequence Head CT Analysis For Children With Shunted Hydrocephalus**JonathanA.Pindrik,MD;EdwardAhn,MD;AylinTekes, MD;ThierryHuisman,MD(Baltimore,MD)
2:14–2:22PM58. Significant Shunt Obstruction Caused by Parenchymal Tissue Shearing During Ventricular Catheter Implantation**JayantPrasannaMenon,MD;KathrynOlson;JonDunbar, BS(SanDiego,CA)
2:22–2:30PM59. Role of Endoscopic Third Ventriculostomy And Choroid Plexus Coagulation in Post Hemorrhagic Hydrocephalus of PrematurityParthasarathiChamiraju,MD;DavidSandberg,MD;JohnRagheb,MD;SanjivBhatia,MD(Miami,FL)
2:30–3:00PMBeverage Break in Exhibit HallGrandBallroom
3:00–3:10PM2011 NREF Young Clinician Investigator AwardSheilaKumariSingh,MD
3:10–4:30PMSCIENTIFIC SESSION VIII – HYDROCEPHALUS II/MISCELLANEOUS
ModeratorsTordD.Alden,MDShenandoahRobinson,MD
3:10–3:18PM60. The Association Between Race And Malignant Shunt FailureRobertPartlowNaftel,MD;NicoleSafiano,BS;MichaelFalola,MD,MPH;JeffreyBlount,MD;WOakes,MD;JohnWellons,MD,MPH(Pittsburgh,PA)
3:18–3:26PM61. Visual Findings in Children With Shunted HydrocephalusJulianJ.Lin,MD;LasunOladeji,BA;AhmadIssawi,MD;LynnLyle,RN(Peoria,IL)
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PROGRAM SCHEDULE
3:26–3:34PM62. Role of Primary Cilia in Developing Chick EmbryosTakayukiInagaki,MD;GarySchoenwolf,PhD(Salt Lake City,UT)
3:34–3:42PM63. Ommaya Ventricular Reservoir Versus Ventriculosubgaleal Shunt For Posthemorrhagic Hydrocephalus: Infection Risks And Ventriculoperitoneal Shunt RatesJoannaWang,BA;AnubhavGautamAmin;VivekMehta, MD;BenjaminCarson,MD;GeorgeJallo,MD;EdwardAhn,MD(Baltimore,MD)
3:42–3:50PM64. Percutaneously-Placed Ventriculo-Atrial Shunts Versus Ventriculo-Peritoneal Shunts: Bringing Back an Old TechniqueTylerAmina;RobertKeating,MD;AmeetChitale,MD;JohnMyseros,MD;AmandaYaun,MD;BhupenderYadav,MD;SureshMagge,MD(Washington,DC)
3:50–3:58PM65. Cerebrospinal Fluid Levels of APP And NCAM-1 Correlate With Ventricular Size in Post-Hemorrhagic Ventricular DilatationDavidDelmarLimbrick,MD,PhD;DiegoMorales, MS;RichardHolubkov,PhD;HaejunAhn,BS;DeannaMercer, BS;TerrieInder,MD,PhD(St.Louis,MO)
3:58–4:06PM66. Erythropoietin Signaling Promotes Oligodendrocyte Development After Prenatal Hypoxic-Ischemic Brain InjuryShenandoahRobinson,MD;LaurenJantzie,PhD(Boston, MA)
4:06–4:14PM67. The Management of Torticollis in Infants And ChildrenCatherineAnneMazzola,MD;LaurenSchwartz,MD;TosanLivingstone,MD;DeborahStraka-DeMarco,PT;TaraGleeson;KaitlynMulhall,RN;StuartWiener,CPO,LPO(Morristown,NJ)
4:14–4:22PM68. Spinal Level of Myelomeningocele Lesion is a Contributing Factor in Posterior Fossa Volume, Intracranial Cerebellar Volume And Cerebellar Ectopia**KieronSweeney;JohnCaird,MD;TaufiqSattar;DavidAllcutt;DarachCrimmins(Donegal,Ireland)
4:22–4:30PM69. Endoscopic Third Ventriculostomy Decreases Ventriculo-Peritoneal Shunt Rate in Posterior Fossa Tumors**Shih-ShanLang,MD;FabioFrisoli,BS;GregoryHeuer, MD, PhD;PhillipStorm,MD(Philadelphia,PA)
4:30–4:45PMAnnual Business MeetingRegencyBallroom
4:45–5:15PMSONS Business MeetingRegencyBallroom
4:45–5:30PMMeet the Leadership Reception For Residents, Fellows And Medical StudentsTheDepot
BREWERY NIGHT AT ANHEUSER-BUSCH 6:00–9:30PMEveningincludestransportation,dinner,beverages,brewerytour,andpicturewiththeClydesdalesBustodepartfromhotelat5:45PMDressisbusinesscasualfortheevening
Special Guest: George Reisch, Brewmaster and Director of Brewmaster Outreach, Anheuser-Busch
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FRIDAY, NOVEMBER 30
6:15–11:00AMRegistrationBallroomFoyer
6:45–7:45AMBreakfast Seminar: Managing Burnout/Stress and Understanding Quality/ValueIllinois/NewYorkCentralRooms
Neurosurgeonsneedtomanageburnoutandstress.Learnhowtoperformwithexcellenceaswellasevaluateandassessyourperformanceasapediatricneurologicalsurgeonusingqualityindicators.
PanelistsLilianaC.Goumnerova,MDPaulKlimoJr.,MD
Attendeeswillreceiveamaximumof1AMA PRA Category 1 CreditsTMforeachBreakfastSeminar.
7:00–11:00AMSpeaker Ready RoomTheDepot
7:15–8:00AMContinental Breakfast in Exhibit HallGrandBallroom
7:15–10:25AMExhibit Hall Open & E-Poster ViewingGrandBallroom
8:00–9:04AMSCIENTIFIC SESSION IX – SPINE/TRAUMAModeratorsRichardC.E.Anderson,MDKurtisIanAuguste,MD
8:00–8:08AM70. Multicenter Immature Large Animal Brain Injury Treatment Trial: Neuroprotection With Cyclosporin AKristenLeighSaliga;SusanMargulies,PhD;ToddKilbaugh, MD;BethCostine,PhD;ColinSmith,MD;CarterDodge,MD;SarahSullivan,MS;ChristopherOwen,MS;SabrinaTaylor,MS;Ann-ChristineDuhaime,MD(Boston, MA)
8:08–8:16AM71. Gene Expression Patterns of CNS Growth And Regeneration at Various Developmental Stages And After Injury**EliasB.Rizk,MD;KristaStewart, BS;SivanMeethal,PhD;NithyaHariharan,MD;BermansIskandar,MD(Harrisburg,PA)
8:16–8:24AM72. CSF Complications Following Intradural Spinal Surgeries in ChildrenVictorLiu,BS;PaulSteinbok,MD(L);ChrisGillis,MD;DougCochrane,MD;AshSinghal,MD,MSC(Vancouver,Canada)
8:24–8:32AM73. Effectiveness And Long Term Clinical Outcome of Conservative Treatment For Lumbar Spondylolysis in ChildrenSantoshiShaliniIndrakanti;RoryMurphy,MD;DeannaMercer;JeffreyLeonard,MD;DavidLimbrick,MD,PhD(SantaRosa,CA)
8:32–8:40AM74. Occipital Condyle to Cervical Fixation in The Pediatric Population**LibbyMarieKosnik-Infinger,MD,MPH;StevenGlazier,MD;BruceFrankel,MD;AveryBuchholz,MD,MPH(Charleston, SC)
8:40–8:48AM75. Evaluation of Hemorrhagic Complications Associated With Perioperative Ketorolac Use in Pediatric Neurosurgery PatientsToddCameronHankinson,MD,MBA;M.Richardson,MD;NicholasPalmeri,BA;SarahWilliams;MichelleTorok,PhD;MichaelHandler,MD(Aurora,CO)
8:48–8:56AM76. Defining Reasonable Medical Certainty in Child Abuse Court CasesMarkS.Dias,MD;BenjaminLevi,MD;WilliamWenner, MD;MarkIantosca,MD;SusanBoehmer,MS(Hershey,PA)
8:56–9:04AM77. Use of MRI-STIR Imaging in Pediatric Traumatic Cervical Spine ClearanceStevenHwang,MD;MarkHenry;KatherineScarlata;AmyKalleen,BS;AlexisChavez,BS;RonRiesenburger,MD;JamesKryzanski,MD;LeslieRideout,RN;AmerSamdani, MD;(Boston,MA)
PROGRAM SCHEDULE
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PROGRAM SCHEDULE
9:04–9:50AMClinical Symposia: Controversies in the Management of Chiari and Syringomyelia
ModeratorMatthewD.Smyth,MD
PanelistsDavidDelmarLimbrick,MD,PhDW.JerryOakes,MD
9:50–9:55AM2013 Toronto Meeting Preview
Meeting Co-ChairsJamesM.Drake,MD,MScAbhayaVivekKulkarni,MDJamesT.Rutka,MD,PhD
9:55–10:25AMBeverage Break in Exhibit HallGrandBallroom
10:25–11:19AMSCIENTIFIC SESSION X – CHIARI/CONGENITALModeratorsAnnMarieFlannery,MDDavidP.Gruber,MD
10:25–10:33AM78. The Importance of a Radiographic Fatty Filum in The Diagnosis of Tethered Cord Syndrome**EricMichaelThompson,MD;MichaelStrong,BS;GarthWarren,MD;NathanSelden,MD,PhD(Portland,OR)
10:33–10:41AM79. Chiari I Malformation And Sports: Evaluating The Risk of Injury**JenniferMaeStrahle,MD;ReginaBower,MD;BelaSelzer, NP;HughGarton,MD;KarinMuraszko,MD;NicholasWetjen,MD;CormacMaher,MD(AnnArbor,MI)
10:41–10:49AM80. Chiari I Malformations: Institutional Experience of 158 Patients Reviewing Symptom Resolution Based on Operative InterventionReneeM.Reynolds,MD;KeikoWeir;DavidBauer,MD;SamuelBrowd,MD,PhD;RichardEllenbogen,MD(Seattle, WA)
10:49–10:57AM81. The Case For International Pediatric Neurosurgical Experiences: A Breakdown of US Resident Experiences With Pediatric Spinal Dysraphism CasesBrandonG.Rocque,MD;HumphreyOkechi,MD;KimberlyFoster,MD;LukeTomycz,MD;JonathanForbes,MD;LelandAlbright,MD;SandiLam,MD(Madison,WI)
10:57–11:03AM82. Isolation of Neural Stem Cells From Myelomeningocele Placodes With Potent Oligodendrocyte Forming AbilitySamuelH.Cheshier,MD,PhD;ShararehGholamin,MD;SiddharthaMitra,PhD;ChaseRichard,BS;MichaelEdwards,MD(Stanford,CA)
11:03–11:11AM83. The Distribution of Cerebellar Tonsil Height Defined by Age: Implications For Understanding Chiari MalformationCormacO.Maher,MD;JenniferStrahle,MD;HughGarton,MD;KarinMuraszko,MD;BrandonSmith,BS(Ann Arbor, MI)
11:11–11:19AM84. Long Term Follow up in Tethered Spinal Cord Following Myelomeningocele ClosureJeffreyP.Blount,MD,FAAP;ChristiBoddiford,BA;BetsyHopson,BA;ChevisShannon,PhD(Birmingham,AL)
11:19–11:24AMHydrocephalus and Shulman AwardsRecipientsAnnounced
11:24–11:29AMClosing Remarks
PRACTICAL CLINICNeuroendoscopy in the Pediatric PatientPracticalAnatomy&SurgicalEducationLab(PASE)
12:00-4:00PMTransportationandlunchareprovided.Bustodepartfromhotelat11:45AM
Theendoscopycoursewillfocusontheintraventricularapproachesforathirdventriculostomy,tumorresectionaswellasremovalofcolloidcysts.Experiencedinstructorswillalsodiscusstheircomplicationsandtehcniquesforavoidance.Participantsthenwillbeabletopracticethesetechniquesinahands-onlab.
FacultyDavidDelmarLimbrick,MD,PhDMarkM.Souweidane,MDJohnC.WellonsIII,MD
Attendeeswillreceiveamaximumof3.5AMA PRA Category 1 CreditsTMforthispracticalclinic.
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ORAL ABSTRACTS
PleaseNote:HydrocephalusandKennethShulmanAwardCandidatesareindicatedwith**
1. EVALUATING INFECTION TRENDS IN PEDIATRIC NEUROSURGICAL PATIENTS: A MULTIDISCIPLINARY PROCESS IMPROVEMENT INITIATIVEChevisShannon,DrPH;KyleAune;StevenVeselsky;AnastasiaArynchyna;AmitaBey;JohnWellons,MD,MPH(Birmingham,AL)INTRODUCTION: Thepurposeofthisstudywastoidentifypotentialriskfactorsassociatedwithsurgicalsiteinfections(SSI)andtoimplementprocessimprovementsthatwillleadtodecreasedincidenceofinfectionsintime.METHODS: Amultidisciplinarytaskforcecomprisedoftendepartmentsrangingfromneurosurgeryandinfectioncontrol,tosterileprocessingandenvironmentalserviceswasestablished.Thegoalwastoevaluateanincreaseinneurosurgicalinfections.Thetaskforceidentified67variablesofinteresttoassess.Aretrospectivechartreviewofallpediatricpatientswhounderwentaneurosurgicalprocedurebetweentheyears2009and2012wasconducted.Demographics,surgicaldata,unitandenvironmentalfactorsandadmission/dischargedatawerecollected.Follow-updatawasreviewedupto6monthspost-optoscreenforinfection.RESULTS: 1,127patientsundergoing2,282neurosurgicalprocedureswereevaluated.Infectionprevalencewas12%(n=143).Numberofprocedures,numberofvisitsperpatient,andpatientdaysin-housewereallfoundtobestatisticallysignificant.CONCLUSIONS: ThisstudyvalidatesliteratureonSSIriskfactorsinthepediatricpopulation,althoughseveralofourfindingswererelevanttopolicychangeswithinourinstitution.Meetingquarterly,ourtaskforcecontinuestodiscussmitigatingcircumstancessurroundingnewinfectionsandtrackdatainordertoevaluatelongtermefficacyofprocesschanges.
2. ESTABLISHING IMPACT NORMS FOR THE LEARNING DISABLED FOLLOWING SPORTS-RELATED CONCUSSION: A NEGLECTED POPULATIONScottZuckerman,MD;YoungLee,BS;MitchellOdom,BS;GarySolomon,PhD;AllenSills,MD(Nashville,TN)INTRODUCTION: Upto16%ofUSchildrenaged3-17yearshaveeitherAttentionDeficit-spectrumDisorder(ADD)oraLearningDisability(LD).Sport-relatedconcussions(SRC)amongyouthathletesrepresentasignificantpublichealthconcern,andneurocognitivetestingisamethodtoevaluateseverityandrecoveryafterSRC.LittlenormativeImmediatePost-ConcussionAssessmentandCognitiveTesting(ImPACT)dataexistsforathleteswithADD/LD.ThegoalofourstudyistoassessbaselineneurocognitivedifferencesbetweenADD/LDvs.non-ADD/LDathletesandestablishnormativedataforthisneglectedpopulation.METHODS: FromAugust2007toMarch2012,baselineneurocognitivetestingusingtheImPACTtestbatterywasperformedamongst6,636highschoolathletes.Ofthetotalparticipants,97hadLDonly,270hadADDonly,55hadbothADDandLD.Averagemeanscoresandstandarddeviationswerecalculatedforeachgrouptoobtainnorms.MultipleregressionanalysiswasusedtotestifADD/LDstatussignificantlypredictedparticipants’baselineneurocognitivescores.RESULTS: Inourmultipleregressionmodel,itwasfoundthatADDsignificantlypredictedVerbalMemory(β=-4.00,p<0.001),VisualMemory(β=-3.63,p<0.001),VisualMotorSpeed(β=-1.63,p<0.001),andReactionTime(β=0.015,p=0.006).LDsignificantlypredictedVerbalMemory(β=-3.32,p=0.001),VisualMemory(β=-3.56,p=0.002),VisualMotorSpeed(β=4.02,p<0.001),andReactionTime(β=0.031,p<0.001).Meansandstandarddeviationswerecalculatedtoprovidenormativevalues.CONCLUSIONS: AthleteswithADDand/orLDhavelowerbaselineImPACTneurocognitivescorescomparedtoathleteswithoutADDandLD.Normativeneurocognitivedataforthesepopulationsareprovided.
3. ESTABLISHMENT OF A MULTIDISCIPLINARY CONCUSSION PROGRAM: IMPACT OF STANDARDIZATION ON PATIENT CARE AND RESOURCE UTILIZATIONJamesM.JohnstonJr.,MD;StevenBrown,BA;SaraWilkins,BA;MichaelFalola,MD,MPH;MarshallCrowther,MD;KimberlyGran,MD;ChevisShannon,PhD(Birmingham,AL)INTRODUCTION: Recentlegislationandmediareportinghasheightenedawarenessofconcussioninyouthsports.Previousworkbyourgroupdefinedsignificantvariationofcareinmanagementofchildrenwithconcussion.WeestablishedamultidisciplinaryconcussionprogramwithauniformmanagementprotocolandemphasisoncommunityoutreachviatraditionalmediasourcesandtheInternet.Thisstudyevaluatestheimpactofstandardizationonpatientcareandresourceutilization.METHODS: Thisretrospectivestudyincludedallpatientsyoungerthan18yearsofageevaluatedforsports-relatedconcussionbetween2007-2012.Emergencydepartment(ED),sportsmedicine,andneurosurgeryrecordswerereviewed.Dataincludeddemographics,injurydetails,clinicalcourse,SCAT2scores,imaging,dischargeinstructions,andreferralforspecialtycare.Thecohortwasanalyzedcomparingpatientsseenbeforeandafterstandardizationofcare.RESULTS: 589patients,270pre(2007-2011)and319post(2011-2012)standardization,wereidentified.Statisticallysignificant(p<.0001)differenceswereseenbetweenthepreandpostgroupsinmultiplevariables:thereweremoregirls,morefirsttimeconcussions,fewerinitialpresentationstotheED,moreconsistentadministrationoftheSCAT2,andmoreconsistentsupervisionofreturntoplayafteradoptionoftheprotocol.CONCLUSIONS: Acombinationofincreasedpublicawarenessandlegislationhasledtoa500%increaseinthenumberofyouthathletespresentingforconcussionevaluationatourcenter.Establishmentofamultidisciplinaryclinicwithastandardizedprotocolhasresultedinsignificantlydecreasedinstitutionalresourceutilizationandmoreconsistentconcussioncareforthisgrowingpatientpopulation.
4. REVIEW OF COMPLICATIONS AFTER ELECTIVE CRANIOTOMY: DOES MY PATIENT NEED TO GO TO THE ICU?AshutoshSinghal,MD,FAANS,FRCSC;JohnKerr,BS(Vancouver,Canada)INTRODUCTION: PatientsareroutinelyadmittedtoICUafterelectivecraniotomy.Althoughthefactorspredictingpost-operativecomplicationshavebeenexploredinadults,thesefactorsarenotfullycharacterizedinchildren.Thepurposeofthisstudywastoexplorethenatureandfrequencyofseriousearlypost-operativecomplicationsrequiringintensivecaremanagement.METHODS: Weconductedaretrospectivereviewofpatients<18yearsoldwithelectivecranialsurgeryatBritishColumbia’sChildren’sHospitalfrom2008-2011.Emergencyprocedureswereexcludedfromthisreview.Studyvariablesincludedpatientdemographics,clinicalhistory,operativedetails,andearlypost-operativecomplicationsrequiringintensivecaremanagement.RESULTS: 76patientswereincludedinourreview,ofwhich70hadanuneventfulpostoperativerecovery,onehadanearlyCSFleak(thediagnosisormanagementofwhichwasnotspecificallyenhancedbytheICUstay),andonerequiredvasoactivedrugsforhypertension.Amongstthe4patients(5.3%)withseriousearlycomplications,3requiredurgentmedicalimagingforunexpectedneurologicaldeficits(1post-operativehematoma,1persistenthydrocephalus,1unremarkableimagingexaminaslowtowakepatient),andonepatientrequiredintubation/ventilationforanunexpectedawakeningdelay.These4patientsallhadanesthetictimesexceeding450minutes,and3hadundergoneposteriorfossatumorsurgery.CONCLUSIONS: Thisstudysuggeststhatchildrenmostatriskforearlyseriouspost-operativecomplications,includingneurologicalandcardio-respiratorycomplications,arethosewithlengthyprocedures,ofteninvolvingtheposteriorfossaorbrainstem.Patientswithshorterproceduresandthosewithsupratentorialpathologymightnotrequirepost-operativeICUmonitoring.
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5. DETECTIBILITY OF IMPLANTED NEUROPATTIES ON INTRA-OPERATIVE RADIOGRAPHS ASSESSED IN A CADAVER MODELDavidDouglasCochrane,MD,FAANS;ThomasLou,BS;JohnMawson,MD;RobertAlmack;ApryilNoga(Vancouver,Canada)INTRODUCTION: Neuropattiescontainradiomarkersforx-raydetection.BCChildren’sHospitalandotherinstitutionsrequireintra-operativeimagingtodetectneuropattieswhenthesurgicalcountisnotreconciled.TheFDAMAUDEdatabasecontainson-goingreportssuggestingthatneuropattiesmaynotbevisualizedonintraoperativeimagesandthereforeareatrisktobeunintentionallyretainedforeignbodies.METHODS: Anadultcadaverwasdrapedanddissectedtosimulateclinicalscenarios.Acircumferentialcraniotomyandoccipitalcraniotomy,andlaminectomywereperformedtoaccesstheanteriorcranialfossa(ACF),posteriorcranialfossa(PCF),andthethoracicandlumbarextraduralspace.Randomizedcombinationsofneuropattiesinfoursizeswereplacedindissectedregionsandimaged.Radiographswereacquiredwithstandardintraoperativex-rayequipmentandtechniquesemployedatourhospital.RadiographswereacquiredinAPandlateralpairs:8pairsfortheACF,4pairsforthePCF,and3pairsforthespine.Astaffradiologistreviewedallradiographsforimplantedneuropatties.RESULTS: Sixty-twoneuropattiesinfoursizeswereimagedacross30radiographs.All½″x3″and1″x3″neuropattieswereidentifiedonradiographs.Some¼″x¼″and½″x½″neuropattiescouldnotbeidentifiedonradiographs.Falsenegativesandfalsepositivesoccurredbecauseofthedegreeofradio-opacityoftheneuropattyandoverlyingsurgicalandanatomicalartifacts.CONCLUSIONS: Theorientationofaneuropattyandtheregionalanatomygreatlyaffectitsvisualizationintheclinicalsetting.Inregionsofcomplexbonyanatomy,½″x½″andsmallerneuropattiesarenotidentifiedwithcompleteaccuracy.
6. A COMPARISON OF COSTS ASSOCIATED WITH ENDOSCOPE-ASSISTED CRANIECTOMY VS. OPEN CRANIAL VAULT REPAIR FOR INFANTS WITH SAGITTAL SYNOSTOSISTimothyW.Vogel,MD;AlbertWoo,MD;AlexKane,MD;KamleshPatel,MD;SybillNaidoo,NP;MatthewSmyth,MD(St.Louis,MO)INTRODUCTION: Surgicalmanagementofinfantswithsagittalsynostosishastraditionallyreliedonopencranialvaultremodeling-(CVR)techniques;however,minimallyinvasivetechnologiesincludingendoscope-assistedcraniectomy-(EAC)repairfollowedbyhelmettherapy-(HT,EAC+HT)isincreasinglyusedtotreatvariousformsofcraniosynostosisduringthefirstyearoflife.InthisstudywedeterminedthecostsassociatedwithEAC+HTincomparisontoCVR.METHODS: Weperformedaretrospectivecase-controlanalysisof21childrenundergoingCVRand21patientsundergoingEAC+HT.Inclusioncriteriaincludedpatientslessthanoneyearofageandoneyearofclinicalfollow-updata.Thefinancialandclinicalrecordswerereviewedfordatarelatedtocostsassociatedwithphysician,hospital,andoutpatientclinicvisits.RESULTS: TheaverageageofpatientsundergoingCVRwas6.8monthsofagecomparedto3.1monthsofageforEAC+HT.PatientsundergoingEAC+HTrequiredtheuseof2helmets-(76.5%)andinfrequentlyrequiredathirdhelmet-(13.3%).EAC+HTwasassociatedwithshorterlengthofstays-(mean=1.10daysversus4.67daysforCVR,p<0.0001),decreasedrateoftransfusions(9.5%versus100%forCVR,p<0.0001),anddecreasedoperativetime-(81.1minutesversus165.8minutesforCVR,p<0.0001).TheoverallcostofEAC+HT,accountingforhospitalcharges,professionalandhelmetcharges,andclinicvisitswasalsolowerthanCVR-($37,255.99forEAC+HTversus$56,990.46,p<0.0001).CONCLUSIONS: EAC+HTisalesscostlysurgicaloptionforpatientswhencomparedtoCVR.Inaddition,EAC+HTwasassociatedwithlowerutilizationofperioperativeresources.ThesefindingssuggestthatEAC+HTforinfantswithsagittalsynostosismaybeacost-effectivefirst-linesurgicaloption.
7. CREATING EVIDENCE-BASED RECOMMENDATIONS FOR THE TREATMENT OF CHILDREN WITH HYDROCEPHALUSAnnMarieFlannery,MD,FAANS,FACS;CatherineMazzola,MD;PaulKlimo,MD;BenjaminWarf,MD;MandeepTamber,MD;JayRivas-Cambrin,MD;DavidLimbrick;JoannaKemp,MD;AsimChoudhri,MD;TinaDuhaime,MD;LissaBaird,MD;DimitiosNikas,MD;KurtAuguste;MarkVanPoppel,MD;LauraRaymond(St.Louis,MO)INTRODUCTION: Evidence-basedmanagementhasbecomeimportantinNeurosurgery.GuidelinesexistinPediatricNeurosurgery,butnotformanagementofhydrocephalus.METHODS: MembersofthePediatricsectionandotherselectedexpertsdiscussedandselectedtopicsandquestionsrelevanttothemanagementofPediatrichydrocephalus.Afterextensivesystematicreviewandvetting,ninereviewtopicsweredeterminedtobeofsignificanceandlikelytohavesomerelevantandreviewableliteraturetosupportthetopics.MeSHtermsweregeneratedandaresearchlibrarianconductedthesearchesoverdatabasesthatincludedPubMed,andTheCochraneCentralRegisterofControlledTrials.Theabstractswerereviewedbytopicsubcommittees,andrelevantpaperswereselectedforfull-textreviewandifappropriate,analysis.Thosepapersfoundtohaverelevancewereanalyzedandevidencetableswerecreated,usingevidence-basedmethodsapprovedbytheJointGuidelinesCommitteeoftheAmericanAssociationofNeurologicalSurgeons(AANS)andtheCongressofNeurologicalSurgeons(CNS).RESULTS: Reviewswereconductedfor:timingofshuntsinprematureinfants,effectofshuntentrypoint,usefulnessoftechnicaladjuvantsforpositioningcatheters,effectivenessofendoscopicthirdventriculostomy,effectofshuntdesignonoutcome,effectivenessofpre/perioperativeantibiotics,effectivenessofothershuntinfectionpreventions,treatmentofshuntinfections,andtheeffectofventricularsizeonoutcome.CONCLUSIONS: Thegoalwastodetermineiftheliteraturehadstatisticallysignificantresultstosupportrecommendationsineachoftheseareas.Theevidencetosupportrecommendationsdemonstratesthelimitationsofthecurrentliterature.
8. PEDSNEUROSURGERY.ORG: A NEW BEGINNINGRichardC.E.Anderson,MD,FAANS;JeffreyLeonard,MD;AnnRitter,MD(NewYork,NY)INTRODUCTION: Since2006,thewebsitefortheAANS/CNSJointSectiononPediatricNeurologicalSurgery(pedsneurosurgery.org)hasbeenhostedbyaprivatecompanyWebsolutions,Inc.Itsplatformusesproprietarysoftwarethathasanoutdateduserinterfacewithverylimitedabilitytomakechanges.Moreover,hostingandworkfeesarehigh.METHODS: In2010,thewebsitecommitteesolicitedproposalsfornewwebsitedesigns.TheAANSandfourindependent,privatecompaniessubmittedproposalsforconsideration.Simultaneously,thewebsitecommitteeconductedasurveyandcollecteddatafromPediatricSectionmembersregardingopinionsanduseofthewebsite.RESULTS: In2011,theexecutivecommitteeapprovedfundingforanewwebsitewithMokaMedia,Inc.asthenewhost.Thenewwebsiteisbasedonopenaccesssoftware(Googlebasedplatform)thatincorporatesacontentmanagementsystem(WordPress)toallowflexibilityofcontentandcontinualupgradesinsoftwareanddesign.Italsosubstantiallyreduceshostingandworkfees.CONCLUSIONS: pedsneurosurgery.orghasrecentlyundergoneamajortransition.Thenewwebsiteincorporatesamorecontemporaryuserinterfaceandhasnewfeaturesthatbenefitsectionmembers.Alivedemonstrationofthenewwebsitewillbepresented.
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9. OCCIPITAL NERVE DECOMPRESSION IMPROVES PEDS QOL SCORES IN CHRONIC DAILY HEADACHE**SohumK.Desai,MD;SudhakarVadivelu,DO;GabrielBrooks,PhD;DeannaDuggan;RobertDauser,MD;AndrewJea,MD;WilliamWhitehead,MD;ThomasLuerssen,MD;RobertBollo,MD;DianaLebron,MD;DanielCurry,MD(Galveston,TX)INTRODUCTION: Approximately1%ofthepediatricpopulationsufferswithChronicDailyHeadache(CDH).CDHcanbeadebilitatingconditionthataffectsboththechildandfamily’squalityoflife.Inadditiontopain,thisconditionimpactsthechild’sacademicperformanceandpsychosocialfunctionatacriticaltimeofdevelopment.WehavepresentedtheimpactofOccipitalNerveDecompressiononthevisualanalogPainscalesofasmallerseriesofpatients.WepresenttheimpactofONDonthepedsQOLscores.METHODS: Themedicalrecordsof21patientswhohadundergoneoccipitalnervedecompressionatTexasChildren’sHospitalwereretrospectivelyreviewed.Pertinentpatientdemographics,clinicalpresentation,andpriortreatmentmodalities,includingpharmacotherapy,anestheticandsteroidinjectionwasrecorded.Pre-andpostoperativephysicalandpsychosocialhealthwasassessedusingthePedsQLMeasurementModel,avalidatedscalebasedon23questionsurveygiventoparentandchild.RESULTS: Therewere7malesand14femalesinourseries.Theaverageageinourserieswas18years(range,13–27years).Allpatientsattemptedothertreatmentmodalities,includingpharmacotherapy,anestheticandsteroidinjection.Ofthe21patientsinourseries,10hadcompletedthePedsQLquestionnairepre-andpost-operatively.Parentsreporteda15.1%andchildrena13.4%improvementinphysicalhealthsummaryscore.Furthermoreparentsreporteda4.4%improvementandchildrena5.1%improvementinpsychosocialhealthsummaryscore.CONCLUSIONS: Neurolysisoftheoccipitalnerveappearstoimprovequalityoflifemeasuresinpatientsandfamilieswithpediatricchronicdailyheadaches.
10. THE IMPACT OF A NOVEL ANALGESIA PROTOCOL ON CHILDREN UNDERGOING SELECTIVE DORSAL RHIZOTOMYRobertMoore,MD;CharlesSchrock,MD;RaniSunder,MD;TracyWester,MD;KatherineKeech,MD;JamesSerot,MD;SoniaShahrawat,MD;SydneyNykiel,DO;T.Park,MD(St.Louis,MO)INTRODUCTION: SelectiveDorsalRhizotomy(SDR)istheonlysurgicalinterventionwithevidencesupportingpermanentreductioninspasticity.Thepost-operativecoursecanbecharacterizedbysignificantdiscomfort.Thisstudyevaluatesanovelanalgesiaregimenutilizingepidurallyinfusedropivacaine–hydromorphonecombinedwithscheduledintravenousketorolac.METHODS: FollowingIRBapproval,theinitial31patientsreceivingepiduralanalgesiawerecomparedwiththeprior41patientswhoreceivedsystemicanalgesiawithafentanylinfusionandscheduleddiazepam.Allsurgerieswereperformedoveranapproximatesix-monthperiodbyasinglesurgeonwithrelativelystandardizedanestheticandnursingcare.Studiedoutcomesincluded:painscores;episodesofseverepain;nausea,itching;oxygendesaturation;andICUadmission.Datawereanalyzedusingt-testandFisherexacttestwhereindicatedwithp<0.05deemedsignificant.RESULTS: Studiedgroupshadsimilardemographics,biometricsanddiseaseburdens.Patientsintheepiduralgrouphadstatisticallyandclinicallysignificantreductionsinpeakrecordedpainscoresforeach4-hourperiodinthefirst28post-operativehours.Severepainwasmarkedlyreducedintheepiduralgroup:9%ofepiduralpatientshadapainscore<5,comparedwith68%ofpatientsreceivingsystemicanalgesia.Fewerepiduralpatientsexperiencedoxygendesaturationduringthefirsttwopost-operativedays(6.5%vs.41%,6.5%vs.39%).NoepiduralpatientsrequiredICUcare.CONCLUSIONS: FollowingSDR,epiduralanalgesiaresultedinsubstantialimprovementsinpaincontrolandsafety.Asimilarprotocolmightbeemployedforothersurgeriesinvolvingalaminectomy.
11. RISK FACTORS FOR BACLOFEN PUMP INFECTIONS: A MULTIVARIATE ANALYSIS**HeatherStevensSpader,MD;RobertBollo,MD;JudyGooch,MD;MarionWalker,MD;JayRiva-Cambrin,MD(Providence,RI)INTRODUCTION: Intrathecalbaclofenpumpshaveaninfectionraterangingfrom4%to50%.Theliteratureindicatesthatcomorbiditiesuniquetothispopulationcontributetothishighinfectionrate.Todate,however,therehasbeennomultivariateanalysisoftheriskfactorsleadingtobaclofenpumpinfectionsinchildren.METHODS: Weconductedaretrospectivecohortunivariateandmultivariateanalysisofpatientswithbaclofenpumpsplacedbetween2000and2012.Medicalrecordswerereviewedforinfection,age,gender,race,BMI,diagnosis,Ashworthgrade,PEG,ventriculo-peritonealshunt,tracheostomy,intraoperativeantibiotics,surgeon,numberofpeoplescrubbed,pumpsizeandlocation,dischargedisposition,CSFleak,wounddehiscence,andspinalfusion.RESULTS: Wereviewed261chartsandfoundaninfectionrateof9.8%.Inthefirstfiveyears,therewasa12%infectionrate,whichdroppedto7%inthelastfiveyears.Thisdecreasedinfectionratecorrelateswiththeimplementationin2008ofastandardizedprotocoltodecreaseshuntinfections.Age,wounddehiscence,andnumberofrevisionswereallindependentriskfactorsforinfection.Ofparticularinterest,BMI,placementlocation(subcutaneousvs.subfascial),andPEG/tracheostomywerenotstatisticallysignificant.CONCLUSIONS: Inourpatientpopulation,baclofenpumpinfectionrateshavebeendecreasing;perhapsasaby-productofaninstitutionalculturechangewithimplementationofastandardizedprotocolforshunts.Wefoundthatlocation,functional,andnutritionalstatusdidnotplaysignificantrolesintheseinfections.Patientswhohaveheretoforebeendeemedhighriskforbaclofenpumpsmayactuallybegoodoperativecandidates.
12. DEEP BRAIN STIMULATION TO TREAT DYSTONIA IN A TRANSGENIC MOUSE MODEL OF RETT SYNDROME: TECHNICAL DESCRIPTIONDanielJ.Curry,MD;AkashPatel,MD;JianrongTang,MD;ZhengyuWu;JavierMata,MD;HudaZoghbi,MD;KirstenUre,PhD(Houston,TX)INTRODUCTION: RettSyndromeisageneticsyndromethatfeaturesintellectualdisability,anddystoniaresultingfromthemutationoftheDNAbindingproteinMeCP-2.Amousemodelpossessingthesamegeneticdefectrecapitulatesthemovementdisabilitiesat8monthsofage.Deepbrainstimulation(DBS)hasbeenusedtotreatprimarydystoniainchildren,thereforeitsapplicationinmousemodelsofgeneticdiseasecanbeatoolintheinvestigationofinterventionsofchildhoodgeneticsyndromes.WereporttheapplicationofDBSinthemousemodelofRettSyndrome.METHODS: SixteenfemaletransgenicmiceheterozygousforMeCP-2mutation,alongwithsixteenFVB.129wildtypemicewereimplantedwithelectrodesintotheentopeduncularnucleusbilaterallyunderanesthesiaofisofluraneat2mg/L.Electrodeswereconstructedfromaanode,50mmtungstenwirepassedthroughacathode130mmcannula,400mmapart.TheentopeduncularnucleuswastargetedbyusingmouseatlasstereotacticcoordinatesAP-1.3,Lateral1.75,andVertical-4.4fromthebregma.Stimulationparameterswerebiphasiccurrentof100mA,130Hz,and100msduration.Behavioralanalysiswasperformedbyassessingopenfieldactivity,hindlimbclasping,nestingscores,andfootslipanalysis.RESULTS: All32micesurvivedtheelectrodeimplantsurgery,usingrigorouscontrolofinhalationalanesthetic.BothtransgenicMeCP-2miceandthewildtypemicewereabletotoleratedailystimulationwithoutobviouscomplication,performingbehaviorassayswhilestimulating.CONCLUSIONS: DeepbrainstimulationinthemousemodelofRettSyndromeisfeasiblethroughmeticulousstereotacticsurgicaltechniqueandcarefulcontrolofanesthesia.
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13. EFFECT OF DEEP BRAIN STIMULATION ON DYSTONIC CEREBRAL PALSY IN CHILDRENJosephRyanKeen,DO;AllisonPrzekop,DO;JoffreOlaya,MD;FrankHsu,MD,PhD;AlexanderZouros,MD(LomaLinda,CA)INTRODUCTION: Cerebralpalsy(CP)isthemostcommoncauseofsecondarydystoniainchildrenandrespondspoorlytomedicaltherapies,especiallythechoreoathetoticsubtype.Althoughdeepbrainstimulation(DBS)isnotwellestablishedforsecondarydystonia,afewstudiesadvocateusingbilateralpallidalstimulationfordystonicCP.WepresentasmallseriesofchildrenwithdystonicCP,whounderwentbilateralpallidalDBS.METHODS: Retrospectivereviewof5consecutivechildren(underage18)withdystonia-choreoathetosisCP,whounderwentDBSofbilateralglobuspallidusinterni(GPi)between2010and2012.OutcomeswereassessedindependentlybytwoauthorsusingtheBarry-AlbrightDystoniaScale(BADS).RESULTS: 5childrenwerediagnosedwithdystonia-choreoathetosisCPsecondarytoinsultsoccurringbeforeage1.Meanageatsurgerywas11withmeanfollow-upof11.4months.Meanelectrodepositionwas20.5mmlateraltotheAC-PClinemidpoint.MeanpreoperativeandpostoperativeBADSscorewas24.0and21.5,respectively,withmeanoverallpercentimprovementof10.63%.Patientswithatleast9monthsfollow-upimproved14.48%withmostsignificantimprovementsoccurringinthosestimulatedthelongest.Twopatientsrequiredremovalofhardwarewithin4monthsofimplantationsecondarytoinfections(1cerebritis,1wound)thatresolvedwithantibiotics.CONCLUSIONS: MeanoverallpercentimprovementinBADSscoreof10.63%,and14.48%forthosestimulatedatleast9months,iscommensuratewithotherpublishedoutcomesof11.73%and15.98%insimilarpopulations.ThisreinforcesDBSasaviabletreatmentoptionforchildhooddystonicCP;however,theremaybeanincreasedriskofinfection.
14. IMPACT OF HYDROCEPHALUS, BIRTH WEIGHT, AND EPILEPSY ON INTELLECTUAL ABILITY IN CEREBRAL PALSY**MeysamAliKebriaei,MD;AnaArenivas,PhD;MatthewGary,MD;KentrellBurks,MD;DonaldBearden,MS;ThomasBurns,PhD;JoshuaChern,MD,PhD(Atlanta,GA)INTRODUCTION: Cerebralpalsy(CP)isthemostcommonmotordisabilityofchildhoodandoftenoccurswithothermedicaldisordersincludingseizures,hydrocephalus,andneurocognitiveimpairments.METHODS: Weevaluatedneuropsychologicalperformancestratifiedonbirthweight,presenceofshuntedhydrocephalus,useofantiepilepticdrugs,presenceofperiventricularleukomalacia,historyofintraventricularhemorrhageandneonataljaundice.131consecutivepatientswithCPreferredforoutpatientneuropsychologicalevaluationwereincludedinourstudy.Meanagewas10years(range5-20).36%weretakingantiepilepticmedicationattimeofstudy.19%hadshuntedhydrocephalus.Birthweightwasclassifiedtobeextremelylowbirthweight(<1,000g)orverylowbirthweight(<1,500g)in24%and20%ofstudypopulation,respectively.Generallinearmodelswereusedtoanalyzedifferencesacrosscategories.RESULTS: Fullscaleintelligencequotient(FSIQ)waslowerwhenshuntedhydrocephaluswaspresent[F(1,108)=9.55,p<.01]andwhenantiepilepticdrugsusewaspresent[F(1,108)=11.6,p<.01].Visualmotorintegrationperformancewaslowerwhenantiepilepticusewaspresent[F(3,48)=10.2,p<.01.NosignificantFSIQdifferenceswerefoundbasedonbirthweightdistribution.NumbersofpreviousshuntrevisionalsofailedtocorrelatewithIQdifferences.CONCLUSIONS: Theresultsofthisstudysuggestshuntedhydrocephalus(butnotthenumberofrevisions)andantiepilepticdruguseinpatientswithCPresultinlowerfullscaleintelligencequotientandvisualmotorintegrationperformance.UnderstandingfactorscontributingtospecificneuropsychologicaldeficitsassociatedwithCPisimportantasitisthemostcommonmotordisabilityofchildhood.
15. ATTEMPTED BLADDER REINNERVATION IN SPINAL CORD INJURY: CLINICAL, ELECTROPHYSIOLOGIC AND HISTOLOGIC OUTCOME AFTER THE XIAO PROCEDUREGeraldF.TuiteJr.,MD,FAANS;BruceStorrs,MD;YvesHomsy,MD;SarahGaskill,MD;EthanPolsky,MD;MargaretReilly,BS;StevenWinesett,MD;LuisRodriguez,MD;CarolynCarey,MD;SharonPerlman,MD;LisaTetreault,RN(St.Petersburg,FL)INTRODUCTION: Anintraduralsomatictoautonomicanastomosis(the“Xiaoprocedure”)hasbeenpreviouslydescribedtocreatea“skin-CNS-bladder”reflexthathasbeenreportedtoimprovebladderandbowelfunctioninpatientswithneurogenicbladderandboweldysfunction.METHODS: Wepresentourexperiencewithone10-year-oldboywithchronicneurogenicbladderandboweldysfunctionrelatedtospinalcordinjury,whounderwenttheXiaoprocedureunderDr.Xiao’ssupervisionaspartofanIRB-approvedmultidisciplinarystudy.RESULTS: AfterundergoingaleftL5ventralroottoleftS2/S3intraduralanastomosis,thepatientreportedthathisbladderandboweldysfunctionimprovedbetweensixandtwelvemonths.However,twoyearsaftertheprocedure,hereportedthattherewasnochangeinhisbladderorboweldysfunctioncomparedtohisconditionpriortotheprocedure.Electrophysiologicalandhistologicalevaluationofthepreviouslyperformedanastomosisduringsurgicalre-explorationthreeyearsaftertheXiaoprocedureshowedthattheanastomosiswasinanatomiccontinuitybutthatneuromaformationhadpreventedreinnervation.Nerveactionpotentialswerenotdemonstrableacrosstheanastomosisandstimulationofthenerveaboveandbelowtheanastomosiscreatednobladderorperinealcontractions.CONCLUSIONS: ThisisthefirstclinicalreportoftheoutcomeoftheXiaoprocedureinachildwithspinalcordinjuryperformedoutsideChina.Ourfindingssuggestthatsomepreviouslyobservedchangescouldberelatedtofactorsotherthantheestablishmentofaskin-CNS-bladderreflexasaresultofasomatictoautonomicanastomosis.
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16. DISRUPTION OF ROLANDIC GAMMA-BAND FUNCTIONAL CONNECTIVITY BY SEIZURES IS ASSOCIATED WITH MOTOR IMPAIRMENTS IN CHILDRENWithEpilepsy**GeorgeM.Ibrahim,MD;TomoyukiAkiyama,MD,PhD;AyakoOchi,MD,PhD;HiroshiOtsubo,MD;MaryLouSmith,PhD;MargotTaylor,PhD;ElizabethDonner,MD;JamesRutka,MD,PhD;O.CarterSnead,MD;SamDoesburg,PhD(Toronto,Canada)INTRODUCTION: Althoughchildrenwithepilepsyexhibitnumerousneurologicalandcognitivedeficits,themechanismsunderlyingtheseimpairmentsremainunclear.Synchronizationofoscillatoryneuralactivityinthegammafrequencyrange(<30Hz)ispurportedtobeamechanismmediatingfunctionalintegrationwithinneuronalnetworkssupportingcognition,perceptionandaction.Here,wetestedthehypothesisthatseizure-inducedalterationsingammasynchronizationareassociatedwithfunctionaldeficits.METHODS: Bycalculatingsynchronyamongelectrodesandperforminggraphtheoreticalanalysis,weassessedfunctionalconnectivityandlocalnetworkstructureofthehandmotorareaoffifteenchildrenwithfocalepilepsyfromintracranialelectroencephalographicrecordings.Functionalconnectivitymetricswerecomparedtoneuropsychologicaloutcomesofmotordexterityandthepresenceofmotorweaknessonneurologicalexamination.RESULTS: Alocaldecreaseininter-electrodephasesynchronyinthegammabandsduringictalperiods,relativetointerictalperiods,withinthemotorcortexwasstronglyassociatedwithclinicalmotorweakness.Gamma-bandictaldesychronizationwasastrongerpredictorofdeficitsthanthepresenceoftheseizure-onsetzoneorlesionwithinthemotorcortex.Therewasapositivecorrelationbetweenthemagnitudeofictaldesychronizationandimpairmentofmotordexterityinthecontralateral,butnotipsilateralhand.Therewasnoassociationbetweenictaldesynchronizationwithinthehandmotorareaandnon-motordeficits.CONCLUSIONS: Thisstudyuniquelydemonstratesthatseizure-induceddisturbancesinneuronaloscillatorydynamicsandfunctionalconnectivityareassociatedwithnetwork-specificneurologicaldeficits.
17. VOLUMETRIC CT ANALYSIS AS A PREDICTOR OF SEIZURE OUTCOME FOLLOWING TEMPORAL LOBECTOMYStevenJ.Schiff,MD,PhD,FAANS;JasonMandell,MS;KennethHill,MD;DanNguyen,MD;KevinMoser,MD;RobertHarbaugh,MD;JamesMcInerney,MD;BryanKaaya;DerekJohnson,BS;WarrenBoling,MD;BenjaminWarf,MD;AndrewWebb,PhD(UniversityPark,PA)INTRODUCTION: Theincidenceoftemporallobeepilepsy(TLE)duetomesialtemporalsclerosis(MTS)canbehighindevelopingcountries.CurrentdiagnosisofMTSreliesonstructuralMRI,whichisgenerallyunavailableindevelopingworldsettings.GivenwidespreadeffectsonbrainstructurebeyondhippocampalatrophyinTLE,weproposedthatCTvolumetricanalysiscanhelppredictoutcomesfollowingresection.METHODS: TenpediatricpatientsreceivedpreoperativeCTscansandtemporalresectionsattheCUREChildren’sHospitalofUganda.Engel’sclassificationofseizurecontrolwasdetermined12monthspostoperatively.TemporallobevolumesweremeasuredfromCTandfromnormativeMRIsusingtheCavalierimethod.Wholebrainandfluidvolumesweremeasuredusingparticlefiltersegmentation.Lineardiscriminationanalysis(LDA)wasusedtoclassifyseizureoutcomebythesebrainvolumes.RESULTS: Epilepsypatientsshowednormaltosmallbrainvolumesandsmalltemporallobesbilaterally.Amultivariatemeasureofthevolumeofeachtemporallobeseparatedpatientsthatwereseizure-free(EngelIA)fromthosewithincompleteseizurecontrol(EngelIB/IIB)withLDA(p<0.01).Temporallobevolumesalsoseparatenormalsubjects,IA,andIB/IIBoutcomes(p<0.01).Additionally,wedemonstratedthatage-normalizedwholebrainvolume,incombinationwithtemporallobevolumes,mayfurtherimproveoutcomeprediction(p<0.01).CONCLUSIONS: Thisstudyshowsstrongevidencethattemporallobeandbrainvolumecanbepredictiveofseizureoutcomefollowingtemporalloberesection,andthatvolumetricCTanalysisofthetemporallobemaybefeasibleinlieuofstructuralMRIwhenthelatterisunavailable.
18. SEIZURE OUTCOMES FOLLOWING STEREOELECTROENCEPHALOGRAPHY-GUIDED RESECTIVE EPILEPSY SURGERY IN CHILDREN: A LONGITUDINAL ANALYSISAriaFallah,MD;GeorgeIbrahim,MD;SumeetVadera,MD;JeffreyMullin,MD;JorgeGonzalez-Martinez,MD,PhD(Toronto,Canada)INTRODUCTION: Stereoelectroencephaloraphy(SEEG)isavaluableandunderutilizedtoolintheevaluationofmedically-intractablefocalepilepsy.Here,wereportseizureoutcomesfollowingstereoelectroencephalography(SEEG)-guidedresectiveepilepsysurgeryinaconsecutiveseriesofchildrenwithdifficulttolocalizeepilepsy.METHODS: Aretrospective,independentchartreviewwasperformedtodeterminetheseizureoutcomesofeligiblepatientsidentifiedthroughaprospectivedatabasemaintainedbytheseniorauthor.Time-to-event(TTE)analysiswasperformed.The‘event’wasdefinedasanyseizurefollowingpostSEEG-guidedresection(notincludingseizuresinthefirstpostoperativeweekandauras).RESULTS: Ninepatients(7males)underwentresectiveepilepsysurgeryattheClevelandClinic,ClevelandUSAfromJuly2009toOctober2010followingSEEGevaluation.ThemeanageofpatientsatthetimeofSEEG-guidedresectionwas13.7±4.4years(range:5-18years.Only3childrenhadanidentifiablelesiononMRI.Pathologywasconsistentwithmalformationofcorticaldevelopmentin6childrenandwasnormalin3children.Themeantime-to-seizurerecurrencewas9.0months(95%CI:4.1-15.0months).EngelClassIoutcomewasachievedin3(33%)patients.SEEGplacementandremovalwasnotassociatedwithanycomplications.CONCLUSIONS: Inthisconsecutivecohortofchildrenwithhighlycomplexmedicallyrefractoryepilepsywithnofurthertreatmentoptionforseizurecontrol,theSEEGmethodprovidedanadditionalopportunityforseizurefreedomin33%ofpatients.Largerseriesandlongerfollow-upareneededtovalidateourresults.
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19. SURGICAL OUTCOME AND PROGNOSTIC FACTORS IN CHILDREN WITH MEDICALLY INTRACTABLE EPILEPSY CAUSED BY FOCAL CORTICAL DYSPLASIABrentRandleO’Neill,MD;AndrewWhite,MD;PramoteLaoprasert,MD;MichaelHandler,MD(Aurora,CO)INTRODUCTION: Focalcorticaldysplasia(FCD)isacommoncauseofmedicallyintractableepilepsy(MIE)andacommonpathologicfindinginpediatricepilepsysurgerycases.PrognosticfactorsinpatientswithFCDaresought.METHODS: AllepilepsysurgerypatientswithFCDoperatedatChildrensHospitalColoradobetween2001and2008wereretrospectivelyanalyzed.Datacollectionincludeageatseizureonset,durationofseizures,development,imagingfindings,FCDtype,FCDlocation,surgerytype,completenessofepileptogeniczone(EZ)resection,andEngeloutcome.Outcomepredictorsweresoughtusingordinallogisticregression.RESULTS: Eighty-twopatientswerestudied.Mediandurationofepilepsypriortosurgerywas67months.Medianfollow-upwas64months.Developmentaldelaywaspresentin44patients.Twenty-fivepatientshadatemporallobefocus.Twelvehadanon-lesionalMRI.Nineteenpatientshadmildmalformationofcorticaldevelopment(mMCD),14hadFCDtype1,23hadFCDtype2and26hadFCDtype3.CompleteresectionoftheEZwasaccomplishedin63patients.Overall,56patients(68.3%)areseizurefree,17(20.7%)haveEngleclass2outcome,9(11%)Engleclass3,andzeroEngleclass4.CompleteresectionoftheEZstronglycorrelatedwithfavorableoutcome(p=0.0001).Normaldevelopmenttrendedtowardfavorableoutcomebutdidnotreachsignificance(p=0.09).FCDtypeandlocationofepileptogeniczoneshowednocorrelationwithoutcome.CONCLUSIONS: ThesefindingsconfirmthebenefitofepilepsysurgeryinpatientswithFCD.CompleteresectionoftheEZisthemostimportantdeterminateofseizureoutcome.
20. NAVIGATING ELOQUENT CORTEX: COMBINED UTILITY OF NEUROIMAGING, NEUROMONITORING AND CORTICAL MAPPING IN ROLANDIC EPILEPSY SURGERYMustafaMoh’DY.Nadi,MD;GeorgeIbrahim,MD;SamuelStrantzas;ElizabethPang;JamesDrake,MD,MSC;JamesRutka,MD,PhD(Toronto, Canada)INTRODUCTION: Peri-Rolandiccorticalresectionsforthetreatmentofmedically-intractableepilepsymaybeassociatedwithconsiderablepost-operativeneurologicaldeficits.MoreaccuratemappingoftheRolandiccortexmaymitigatetherisktopatients.Here,weevaluatethecombinedutilityofmagneticresonanceimaging(MRI),magnetoencephalography(MEG),neuromonitoringandcorticalmappinginguidingRolandicresections.METHODS: AretrospectivechartreviewwasperformedofpatientswhounderwentresectiveepilepsysurgeryinvolvingRolandiccortexattheHospitalforSickChildren.Theprimaryoutcomesofinterestweretheconcordanceofpre-operativeandintra-operativemodalitiesinlocalizingtheprecentralsulcus,aswellasseizureandneurologicaloutcomesfollowingRolandicresection.RESULTS: Eightchildren(4males)withameanageof13.6yearsandmeanepilepsydurationof9.0yearswereincludedinthestudy.StructuralMRIwasnormalin3patients(37.5%),whereastheremainingdemonstratedaperi-Rolandiccorticalabnormality.MEGevoked-potentials,intraoperativeneuromonitoring(phasereversal)andcorticalmappingusingatrains-of-fiveparadigmidentifiedtheRolandiccortexinallpatients.ThePenfieldcorticalmappingparadigmwasunsuccessfulin2patients(33%).Sevenpatientsunderwentextraoperativemappingbyconsecutivelystimulatingimplantedelectrodes,whichsuccessfullyidentifiedthemotorstripinallsubjects.Sevenpatientsexperiencedexpectedhemiparesisimmediatelypost-operatively,allofwhomwereambulatorywithin6months.Allpatientsachievedasatisfactoryseizureoutcome(EngelclassIorII).CONCLUSIONS: Combiningnon-invasiveneuroimagingwithintra-andextra-operativecorticalmappingprovidesrobustlocalizationofRolandiccortex,whichmaymitigateiatrogenicneurologicaldeficitandguidemoreinformedpre-surgicaldiscussions.
21. SURGERY FOR INTRACTABLE EPILEPSY DUE TO UNILATERAL BRAIN DISEASE: A RETROSPECTIVE STUDY COMPARING HEMISPHERECTOMY TECHNIQUESSubashLohani,MD;AnnaPinto,MD;AnnBergin,MD;BlaiseBourgeois,MD;PeterBlack,MD;SanjayPrabhu,MD;JosephMadsen,MD;MasanoriTakeoka,MD;AnnapurnaPoduri(Boston,MA)INTRODUCTION: Themajorsurgicalapproachesforhemispherectomyare:anatomichemispherectomy(AH),traditionalfunctionalhemispherectomy(FH),andperi-insularhemispherotomy(PIH).Wedescribetheoutcomeafterhemispherectomyinchildrenwithsevereunilateralcorticaldiseasesecondarytoacquiredbrainlesionsvs.developmentallesions.METHODS: WeconductedaretrospectivechartreviewofpatientswhounderwenthemispherectomyatBostonChildren’sHospitalbetween1997–2011.OutcomeaftersurgerywasmeasuredwiththeEngelscoreat12months.SecondaryoutcomewasmeasuredintermsofreoperationandneedforVPshunt.RESULTS: Among36consecutivepatients,group1(n=14)hadstaticacquiredlesions,andGroup2(n=22)haddevelopmentallesions.Outcomerelatedtoseizurecontrolwasgoodinbothgroups(EngelscoreIfor25).InGroup1,fivepatientsunderwentAH,sixunderwentFH,andthreeunderwentPIH;nonerequiredasecondprocedure.InGroup2,14hadAH,sixhadFH,andtwohadPIH.InGroup2,amongtwopatientswhohadFH,onerequiredreoperationtocompletethedisconnectionbyAH,andonesubsequentlyunderwentcompletionPIHduetopersistentseizures.TwomorepatientsrequiredrepeatPIH.Amongfourpatientneedingreoperation,twohadmalformationsofcorticaldevelopment(MCD)andtwohadhemimegalencepahly.13patientsneededVPshuntplacement,allofwhichunderwentAHbutone.CONCLUSIONS: Ourdatasuggestsgoodseizureoutcomefollowinghemispherectomyineithergroupswitheitherapproaches.WeobservedahighercomplicationratewithAH.Patientswithdevelopmentallesionsareatsmallriskofneedforreoperation.
22. MRI GUIDED STEREOTACTIC LASER THERMAL ABLATION TECHNIQUE IN EPILEPSY SURGERY – OUR INITIAL EXPERIENCEParthasarathiChamiraju,MD;SanjivBhatia,MD;JohnRagheb,MD;SantiagoMedina,MD,MPH;NolanAltman,MD;EsperanzaPacheco,MD;IanMiller,MD(Miami,FL)INTRODUCTION: CorticalresectionwithintraoperativeECOGisthestandardtreatmentforpatientswithrefractorylesionalepilepsy.WepresentfourpatientswithcorticalabnormalitiestreatedwithstereotacticplacementoflaserprobeandthermalablationunderMRIguidance.METHODS: WeretrospectivelyreviewedthemedicalrecordsoffourepilepsypatientstreatedwithMRIguidedstereotacticlaserthermalablationforcorticalabnormality.Onepatientwastreatedprimarilywiththistechnique,andinotherthreepatients,thiswasusedtotreatmarginsofprioropensurgicalresection.FramebasedstereotaxywasusedforplacementoffibreopticprobeinthelesionandwithMRIguidancelaserthermalcoagulationwasperformed.RealtimeMRimagesallowedliveevaluationoftargettemperatureandprotectionofsurroundingtissues.RESULTS: Theprocedurewaswelltoleratedbyallpatientswithnoperioperativecomplications.Followingablation,thelesionshowedlowT2weightedsignalconsistentwithproteindenaturalisationandahaloofsurroundingrestrictionindiffussionsuggestiveofischemiaorinfarction.PostproceduralfollowupshowstwopatientsatEngelclassI(seizurefree),oneofwhomrequiredsecondablation.Inpatientswhowerenotcured,onewasEngelclassIIIandtheotheratEngelclassIV.Meanlengthofhsopitalstaywas1.6days.CONCLUSIONS: ThispreliminaryexperiencewithStereotacticlaserthermalablationunderMRIguidanceinchildrenwithmedicallyrefractorylesionalepilepsydemonstratesthatthisapproachcanbeusedsafely.Thistechniquemaybeasuitablealternativetoopenresectionandlongtermfollowupisrequiredforbetterunderstandingofseizurecontrol.
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23. PREDICTORS OF SEIZURE OUTCOMES IN CHILDREN WITH TUBEROUS SCLEROSIS COMPLEX AND INTRACTABLE EPILEPSY UNDERGOING RESECTIVE EPILEPSY SURGERY: AN INDIVIDUAL PARTICIPANT DATA META-ANALYSIS**AriaFallah,MD;GordonGuyatt,MD,MSC;O.CarterSneadIII,MD;ShanilEbrahim;GeorgeIbrahim,MD;AlirezaMansouri,MD;DevenReddy,MD;StephenWalter,PhD;AbhayaKulkarni,MD,PhD;MohitBhandari,MD,PhD;LauraBanfield,MS;NeeraBhatnagar;ShuliLiang,MD,PhD;FedericaTeutonico,MD;JianxiangLiao,MD,PhD;JamesRutka,MD,PhD(Toronto,Canada)INTRODUCTION: Weperformedasystematicreviewandindividualparticipantdatameta-analysistoidentifypreoperativefactorsassociatedwithagoodseizureoutcomeinchildrenwithTuberousSclerosisComplexundergoingresectiveepilepsysurgery.METHODS: Wesearchedelectronicdatabases(MEDLINE,EMBASE,CINAHLandWebofScience),archivesofmajorepilepsyandneurosurgerymeetings,andbibliographiesofrelevantarticles,withnolanguageordaterestrictions.Weincludedcase-controlorcohortstudiesofconsecutiveparticipantsundergoingresectiveepilepsysurgerythatreportedseizureoutcomes.Toidentifypredictorsofagoodseizureoutcome(i.e.EngelClassIorII)weusedlogisticregressionadjustingforlengthoffollow-upforeachpreoperativevariable.RESULTS: Of9863citations,20articlesreportingon181participantswereeligible.Goodseizureoutcomeswereobservedin126(69%)participants(EngelClassI:102(56%);EngelclassII:24(13%)).Inunivariableanalyses,absenceofgeneralizedseizuresemiology(OR=3.1,95%CI=1.2-8.2,p=0.022),noormilddevelopmentaldelay(OR=7.3,95%CI=2.1-24.7,p=0.001),unifocalictalscalpelectroencephalographic(EEG)abnormality(OR=3.2,95%CI=1.4-7.6,p=0.008)andEEG/Magneticresonanceimagingconcordance(OR=4.9,95%CI=1.8-13.5,p=0.002)wereassociatedwithagoodpostoperativeseizureoutcome.CONCLUSIONS: Smallretrospectivecohortstudiesareinherentlypronetobias,someofwhichareovercomeusingindividualparticipantdata.Thebestavailableevidencesuggestsfourpreoperativefactorspredictiveofgoodseizureoutcomesfollowingresectiveepilepsysurgery.GiventhelowincidenceofchildrenwithTuberousSclerosisComplexundergoingepilepsysurgery,largelong-termprospectivemulticenterobservationalstudiesarerequiredtofurtherevaluatetheriskfactorsidentifiedinthisreview.
24. FROM TWO SURGERIES TO ONE: ADVANCED NEUROIMAGING REDUCES INVASIVE MONITORING IN PEDIATRIC EPILEPSY SURGERYPankajKumarAgarwalla,MD;ElizabethThiele,MD,PhD;RonaldThibert,MD;CatherineChu-Shore,MD;BradleyBuchbinder,MD;StevenStufflebeam,MD;PaulCaruso,MD;MirelaSimon,MD;Ann-ChristineDuhaime,MD(Boston,MA)INTRODUCTION: Surgicalmanagementofepilepsyinchildrentraditionallyrequiresimplantationofintracranialelectrodestolocalizeepileptogeniccortexandmapfunction,andasecondtherapeuticsurgeryforresection.Intraoperativeimageguidancemergingstructuralandtractographydatawithmagnetoencephalogram(MEG),PET,andfMRI,alongwithintraoperativecorticographyandfunctionalmapping,canproviderequisiteinformationonbothefficacyandsafetyofresectioninonesurgicalprocedureforselectedpatients.Wenoticedadecreaseinuseofinvasivemonitoringduringthepastseveralyearsasourconfidenceinnoninvasivemethodshasincreased.Wereportourrecentexperienceforchildrenwithnon-neoplasm-relatedintractableepilepsyinwhominvasivemonitoringwasconsidered,butwhoinsteadunderwentsinglestagesurgeriesrelyingonthesetechniques.METHODS: Patientsrangedfrom3to11yearsold(median=4years).Diagnosesincludetuberoussclerosis,corticaldysplasia,neonatalhemorrhage,andencephalitis.Coregistrationofhigh-resolutionstructuralimaging,tractography,MEG,andPETdefinedinitialtargetfor,andlimitsof,resection.Intraoperativecorticographybeforeandafterresectionalsohelpeddefinecompletionofresection,andfunctionalmappingofmotorandtractdatawasusedtopreservefunction.RESULTS: Post-operatively,allpatientshaveremainedseizurefree(EngelI-rangeoffollow-up1to6months)withnonewfocalneurologicaldeficit.CONCLUSIONS: Multi-modalitynon-invasivepreoperativeevaluationmergedwithintraoperativeimageguidanceandfunctionalmappingmayhelpreducetheneedforchronicsubduralanddepthelectrodemonitoringinchildrenwithintractableepilepsy.Furtherfollowupandlargerserieswillbetterdefinetheutilityandlimitsofthisapproach.
25. FUNCTIONAL LESIONECTOMY: A MINIMALLY RESECTIVE STRATEGY EFFECTIVE IN CHILDREN WITH MRI-NEGATIVE, INTRACTABLE EPILEPSYJohnRagheb,MD;SanjivBhatia,MD,FAANS,FACS;AnnHyslop,MD;IanMiller,MD;PrasannaJayakar,MD(Miami,FL)INTRODUCTION: Excisionalsurgeryachievesseizure-freedominalargeproportionofchildrenwithMRInegativeepilepsy,buttheresectionsbasedonfunctionaldataareoftenextensive.WeexploredthepossibilitythatmorerestrictedresectionswithinacarefullyselectedMRInegativecohortcouldachievecomparablesuccess..METHODS: Wereportasubsetof25childrenwithMRI-negative,intractablepartialepilepsywhounderwentfocalcorticectomyatourinstitutionbetweentheyearsof2005-2011.Theepileptogenicregionwasidentifiedbyintegratingmultimodalfunctionaldata.Corticectomieswereminimizedbyresectingregionsthatshowedconvergenceofmultimodalabnormalitiesincluding3-DEEGsourcelocalization,SPECT,PETandinvasiveEEGdata.RESULTS: ResectionswereconvergentwithscalpEEGinallcases,3-DEEGsourcelocalizationofscalpinterictaldatain9,focalictalSPECThyperperfusionin10,highlylocalizedPEThypometabolismin8andhypermetabolismin2,focalinterictaland/orictaldischargesonintraoperativeECoGin23,andfocalictalonsetduringextraoperativesubduralmonitoringin13patients.Resectionswereconsideredcompletein7andincompletein18.At1yearfollow-up,13/25(52%)wereseizure-free,5(20%)experiencedpersistentseizureswith<90%reductioninfrequency,andtheremaining7(28%)hadnochangeinseizureburden.Outcomeswereunrelatedtocompletenessofresectionortypeofcorticaldysplasia.CONCLUSIONS: OurfindingsdemonstratethatfunctionallesionectomyissuccessfulinaselectedsubsetofMRInegativecohort.Minimizingresectionbasedonconvergentmulitmodalfunctionaldatahelpsavoidunnecessarilylargeresectionsandmayhaveimportantimplicationsforseizurecontrolanddevelopmentaloutcome.
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26. CALVARIAL THICKNESS AND DIPLOIC SPACE DEVELOPMENT IN CHILDREN WITH SAGITTAL SYNOSTOSIS ASSESSED BY COMPUTED TOMOGRAPHYTrinaGhosh;GarySkolnick,BA;HankSun,BA;KamleshPatel,MD;MatthewSmyth,MD;AlbertWoo,MD(KansasCity,MO)INTRODUCTION: Wecomparecalvarialthickness(CALV)anddiploicthickness(DIPL)inchildrenwithcorrectedsagittalsynostosistothoseofnormalcontrols.Wealsocomparethesemeasuresinchildrenaftercorrectionbyanopen(OPEN)orendoscopic(ENDO)approach.METHODS: Post-operativeCTscansofchildrenwithsagittalsynostosiscorrectedbyOPEN(n=26)orENDO(n=26)approachwerecomparedtocontrolswithoutcraniosynostosis(n=47).CALVandDIPLweremeasuredusingAnalyze11.0at40pointsover4zones:frontal,anteriorparietal,posteriorparietal,andoccipital.RegressionanalysiswasusedtocompareCALVandDIPLcontrollingforgenderandage.RESULTS: AdjustedmeanDIPLwaslessinpost-operativepatientswithsagittalsynostosiscomparedtonormalcontrols(0.19±0.06mm,p=0.002).AdjustedmeanCALVwasequivalentinbothgroups(p=0.98).However,inpatientswithsagittalsynostosisCALVwasthickerinthefrontalzone(p=0.002).DIPLinOPENandENDOsubjectswereequivalent(p=0.977).ENDOcalvariawerethinner(meanadjustedoveralldifference0.65±0.27mm,p=0.020).Ageofsubjectsrangedfrom10monthsto14.75years(mean=2.47years).Ageattimeofscanwasasignificantfactor(p<0.001).Genderwasnotasignificantfactor(p<0.20).CONCLUSIONS: ChildrenwithcorrectedsagittalsynostosishavethinnerDIPLandequivalentCALVwhencomparedtonormalcontrols.Aftercorrection,CALVislessbytheENDOapproachcomparedtotheOPENapproach;thereisnodifferenceinDIPL,however.
27. LESS-INVASIVE PEDICLED OMENTAL-CRANIAL TRANSPOSITION IN PEDIATRIC PATIENTS WITH MOYAMOYA DISEASE AND FAILED PRIOR REVASCULARIZATIONKevinZ.J.Chao,MD;RamonNavarro,MD;PeterGooderham,MD;MatiasBruzoni,MD;SanjeevDutta,MD;GarySteinberg,MD,PhD(PaloAlto,CA)INTRODUCTION: PatientswithMoyamoyadiseaseandprogressiveneurologicdeteriorationdespitepreviousrevascularizationposeamajortreatmentchallenge.Manyhaveexhaustedtypicalsourcesforbypassorhaveischemiainareasthataredifficulttoreachwithanindirectpedicledflap.Omental-cranialtranspositionisaneffectivebutsparinglyusedtechniquebecauseofitsassociatedmorbidity.METHODS: Wehaverefinedalaparoscopicmethodofharvestinganomentalflapthatpreservesitsgastroepiploicarterialsupply.Thepedicledomentumcanbelengthenedasneededbydividingitbetweenthevasculararcades.Itistransposedtothebrainviaskipincisions.Theflapcanbetrimmedorstretchedtocoverischemicareasofthebrain.Thecranialexposureisperformedinparallel.RESULTS: Weperformedthistechniqueinthreepediatricpatients(agedfivetotwelveyears)withMoyamoyadisease,priorSTA-MCAbypasses,andprogressiveischemicsymptoms.Inonepatient,wetransposedomentumtobothhemispheres.Bloodlossrangedfrom75to250ml.Thepatientstoleratedadietimmediatelypostopandweredischargedinthreetofivedays.Allthreechildren’sischemicsymptomsresolvedwithinthreemonthspost-operatively.MRIatoneyearshowedimprovedperfusionandnonewinfarcts.Angiographyshowedexcellentrevascularizationoftargetedareasandpatencyofthegastroepiploicarterialpedicle.CONCLUSIONS: Laparoscopicomentalharvestforcranial-omentaltranspositioncanbedoneefficientlyandsafely.Patientsappeartotoleratethistechniquemuchbetterthanlaparotomy.Wecanachieveexcellentangiographicrevascularizationandresolutionofischemicsymptoms.
28. INTRA- AND INTER-RATER RELIABILITY OF THE PEDIATRIC AVM COMPACTNESS SCOREFabioFrisoli;Shih-ShanLang,MD;ArastooVossough,MD,PhD;AnneMarieCahill,MD;HishamDahmoush,MD;GregoryHeuer,MD,PhD;PhillipStorm,MD;LaurenBeslow,MD(Philadelphia,PA)INTRODUCTION: Cerebralarteriovenousmalformations(AVM)haveahigherpost-resectionrecurrencerateinchildrenthaninadults.OurpreviousstudydemonstratedthatadiffuseAVM(lowcompactnessscore)predictspost-resectionrecurrence.Theaimsofthisstudyweretoevaluatetheintra-andinter-raterreliabilityofourAVMcompactnessscore.METHODS: Angiogramsof24patientsassignedapreoperativecompactnessscore(scaleof1to3,1=mostdiffuse,3=mostcompact)inourpreviousstudywerere-ratedbythesameneuroradiologist9monthslater.Apediatricneurosurgeon,pediatricneuroradiologyfellow,andinterventionalradiologistblindedtoeachother’sratings,theoriginalratings,andAVMrecurrencealsoratedeachAVM’scompactness.Theintra-andinter-raterreliabilitieswerecalculatedusingthekappa(κ)statistic.RESULTS: Ofthe24AVMs,scoresbytheoriginalneuroradiologistwereascoreof1in6,2in16,and3in2AVMs.Theintra-raterreliabilitywas1.0.Theκamongthefourraterswas0.69[95%confidenceinterval(CI)0.44-0.89],whichindicatessubstantialreliability.Theinter-raterreliabilitybetweentheneuroradiologistandneuroradiologyfellowwasmoderate(κ=0.59,95%CI0.20-0.89)andwassubstantialbetweentheneuroradiologistandneurosurgeon(κ=0.74,95%CI0.41-1.0).Theneuroradiologistandinterventionalradiologisthadperfectagreement(κ=1.0).CONCLUSIONS: Intra-andinter-raterreliabilityofAVMcompactnessscoringwereexcellentandsubstantial,respectively.TheseresultsdemonstratethattheAVMcompactnessscoreisreproducible.However,sincetheneuroradiologistandinterventionalradiologisthadperfectagreement,thisindicatesthatthecompactnessscoreismostaccuratelyappliedbythosewithextensiveangiographyexperience.
29. SKULL GROWTH AND CRANIAL VAULT VOLUMES IN SAGITTAL SYNOSTOSISRahelGhenbot;GarySkolnick,BS;KamleshPatel,MD;SybillNaidoo,NP;MatthewSmyth,MD;AlbertWoo,MDINTRODUCTION: Therehavebeenconflictingreportsonhowsagittalsynostosisaffectscranialvaultvolume(CVV)andwhichsurgicalapproachbestnormalizesthevolume.Inthisstudy,wecomparetheCVVandcranialindex(CI)ofchildrenwithsagittalsynostosis(beforeandaftersurgery)tothoseofcontrols.Wealsocomparetheeffectofsurgerytype.METHODS: CTscansof33childrenwithsagittalsynostosisand40ageandgendermatchedcontrolswereevaluatedusingAnalyze11.0andpreviouslyvalidatedautomatedsegmentationsoftwareforCVV.16casesunderwentopensurgery(open),16underwentendoscopicsurgery(endo).RESULTS: TheadjustedmeanCVVforcasesbeforesurgerywas42ccsmallerthancontrols(p=0.174).TheadjustedmeanCVVofpostoperativechildrenwas1.5cclarger(p=0.971).Therewasnosignificantdifferencebetweenopenandendocases’CVVspostoperatively(p=0.305).TheCIincreased12%±6%inbothopenandendocases;therewasnosignificantdifferenceinmeanCI(p=0.141)betweenthetwogroups.TherewasatrendtowardgreaterCVVgrowthaftersurgeryinendocases(ascomparedtoopen)(p=0.082).CONCLUSIONS: YoungchildrenwithsagittalsynostosishavenosignificantdifferenceinCVVcomparedtocontrols.ThetypeofsurgerydoesnotseemtoaffectCIandCVVoneyearpostoperatively.BothproceduresresultinCVVssimilartothatofcontrols.Thedatahintthatgrowthpost-surgerymaybegreaterinchildrenwhoundergotheendoscopicprocedure,butgreaterpowerisneededtofullyevaluatethishypothesis.
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30. ANTERIOR FONTANELLE SIZE AND CLOSURE IN FULL TERM CHILDREN BASED ON HEAD COMPUTED TOMOGRAPHY**JonathanA.Pindrik,MD;BoramJi,BS;CourtneyPendleton,MD;EdwardAhn,MD(Baltimore,MD)INTRODUCTION: Anteriorfontanellesizeandtimeofclosurevaryconsiderably.Moststudiesneglectpopulationcharacteristicsofanteriorfontanellesandimplementclinicalmeasurementtechniques.Thisstudyprovidescomputedtomography(CT)acquiredrangesofanteriorfontanelleclosure(AFC)andsurfacearea(SA)acrossmonthlyagegroupsofchildren.METHODS: Highresolution3-dimensionalreconstructedheadCTscansoffulltermchildrenwithoutcongenitalorchronicstructuralneurologicabnormalitybetweenages0and24monthswereretrospectivelyreviewed.IntersectionofcoronalandsagittalsuturesindicatedAFC.Measurementoffontanellewidth(W)andantero-posterior(AP)diameterbasedontangentialoutlinesofpatentfontanellesallowedapproximationofanteriorfontanelleSA(SA=W*AP*[1/2]).AFCprevalenceandmedianSAwithstandarddeviationwerecalculatedforeachagegroup.RESULTS: Between15and23headCTscanspermonthlyagegroup(0-24months)werereviewed,totaling464scans.ThefrequencyofAFCincreasedsteadilyfrom9to24months(9months:5.3%;24months:90.0%),andreachedabove50%atage16months(52.9%).Betweenages20-24months,AFCprevalenceremainedbetween87.5-90.0%.DramaticchangesinmedianSAoccurredbetweenages4-5,9-10,and13-14months(4months:954.4mm2;5months:623.2mm2;9months:444.9mm2;10months:225.3mm2;13months:176.6mm2;14months:59.9mm2).MediananteriorfontanelleSApeakedatage2months(1022.2mm2).CONCLUSIONS: Radiographiccross-sectionalstudiespresentpopulationcharacteristicsofAFCandSAacrosspediatricmonthlyagegroups.
31. PEDIATRIC MOYA-MOYA: SURGICAL VARIATION, SEIZURE OUTCOMES, AND ANGIOGRAPHIC FOLLOW-UP**LukeTomycz,MD;AtoWallace,BS;LailaHaasan-Malani;PeterMorone,MD;RobertSinger,MD;RobertMericle,MD(Nashville,TN)INTRODUCTION: Althoughithasbecomewell-acceptedthatencephalo-duro-arterio-(myo)-synangiosis(EDAS/EDAMS)resultsinexcellentoutcomesforchildrenwithMoya-Moya,occasionaltreatmentfailuresmandatefurtherstudytodeterminethebestinterventionforeachpatient.METHODS: WeanalyzedalltheEC-ICby-passcasesperformedonMoya-MoyapatientsatVanderbiltChildren’sHospital(VCH)since2006.Foreachpatient,thefollowingdatawasrecorded:typeofsurgery,operativetime,estimatedbloodloss,durationofstay,complications,seizureoutcome,andstatusatlastclinicalandangiographicfollow-up.ThemostcommonlyperformedprocedurewastheEDASorEDAMSindirectby-pass,howeverdirect,end-to-side,STA-MCAby-passwassuccessfullyperformedintwopatientsandattemptedinathirdpatientbutabortedduetosmallvesselcaliber.RESULTS: Seventeenpatientsweretreatedwithby-passproceduresperformedonatotaloftwenty-eighthemispheres.NineweredeemedtohaveMoya-MoyasyndromebecauseofassociatedconditionssuchasNF1(2/17),Down’ssyndrome(3/17),orsicklecellanemia(4/17).Meanoperativetime,estimatedbloodloss,andmeanhospitalstaywere330minutes,178mL,and2.5days,respectively.Nopatientexperiencedfurtherstrokesfollowingsurgeryalthoughanumberofminorcomplicationswerenoted.CONCLUSIONS: EC-ICby-passisasafeandrelativelysimpleinterventionwhichprovidesexcellentprotectionfromfutureischemiceventsinchildrenwithMoya-Moyadisease.Outcomesseemtobeequivalentinpatientswith“Moya-Moyasyndrome”.Theeffectofsurgeryonseizuresisvariable.Interestingly,post-operativeangiographicrevascularizationwasnotalwaysevidenteveninsomepatientswhoenjoyedagoodclinicaloutcome.
32. FEATURES OF CEREBRAL ARTERIOVENOUS MALFORMATIONS IN CHILDRENAndreiB.Talanov,MD,PhD(Ivanovo,RussianFederation)INTRODUCTION: Clinicalandtheoreticalstudiesindicateacertainchangeabilityofcerebralarteriovenousmalformations(AVMs)duringlifetime.ThisresearchwasaimedatestimationofAVMsfeaturesinchildrenincomparisonwithadults.METHODS: Thestudywascarriedoutin273prospectivelycollectedpatients(165men,108women,meanage23,9years).PatientswerehospitalizedatsurgicaldepartmentsofBurdenkoNeurosurgicalInstitutefromJanuary1986tillSeptember2002.Therewere85children(agelessthan15years)and188adults.Thefollowingcharacteristicswereanalyzed:gender,typeofpresentation(hemorrhagic,non-hemorrhagic),arterialsupply(cortical,non-cortical),drainingsystem(compact,diffuse),nidus(fistula,plexiform),location(supratentorialsuperficialanddeep,subtentorial);presenceorabsenceofangiomatouschangers,intranidalaneurisms,associatedaneurismsandvenousvarixes.Chi-squarestatisticswasused.Significancewasacceptedwhenpwaslessthan0,05.RESULTS: Therewaspredominanceofmale(plessthan0,05),fistulas(plessthan0,0005),subtentorialAVMs(plessthan0,005)andintranidalaneurisms(plessthan0,05)inchildren.Associatedaneurismsandangiomatouschangerswerelesscommoninchildrenthaninadults(plessthan0,05andplessthan0,01respectively).Differencesinothercharacteristicswerenotsignificant.CONCLUSIONS: CerebralAVMsinchildrenandadultsaredissimilarpathology.Alongwithlifetimechangers,probably,therearevariantsofAVMsthedifferencebetweenwhichisdeterminedcongenitally.PredominanceofcertainAVMsindifferentperiodsoflifemaybeexplainedbyphasehemodynamicchangersimpliedinbiophysicalprinciples.
33. MULTI-CONCENTRIC OSTEOTOMY FOR CORRECTION OF CRANIAL DEFORMITIES: CASE SERIES AND FOLLOW-UPJenniferGentrySavage,MD;MicamTullous,MD;PatriciaMancuso,MD(SanAntonio,TX)INTRODUCTION: Theauthorsreportacaseseriesandin-depthdescriptionofthemulti-concentricosteotomytechnique,MCO,whichisutilizedtoprovideimmediatecorrectionofexistingdeformities,primarilyscaphocephalyassociatedwithsagittalsynostosis.METHODS: 21patientsrangingfromage7-24monthswithscaphocephalysecondarytosagittalsuturesynostosisand9patientsfromage1-9yearswithsevereplagiocephaly,underwentcranialvaultremodelingandexpansionutilizingtheMCOtechnique.Forpatientswithscaphocephalysecondarytosagittalsynostosis,bilateralMCOswereperformed,allhingingonthecoronalsuture.Afterachievementofappropriatecontour,absorbableplatesandscrewswereappliedtotheposterioraspectoftheconstructforstabilization.Forpatientswithsevereplagiocephaly,MCOwascustomizedforcorrectionofthespecificdeformity.RESULTS: Allpatientsdemonstratedimmediatepost-operativecorrectionofthedeformityandallconstructsmaintainedtheiroriginalshapeandposition.Pre-operativecranialindexmeasurementsinthesagittalsynostosisgrouprangedfrom59-67(meanof64)andpostoperativecranialindexesrangedfrom68-82(mean75)givinganoverallincreaseincranialindexof9-14withameanincreaseof11.Therewerenoincidencesofpost-operativeintracranialhypertension.CONCLUSIONS: TheMCOprocedureallowsforcranialexpansionandcorrectionofbiparietalnarrowingassociatedwithsagittalsynostosisinadditiontootherfocalcranialdeformities.Thistechniqueofferstheabilitytoperformtheosteotomiesin-situallowingforpreservationofthesutures,whenfeasible,andalsoallowsforreducedmanipulationtherebydecreasingoperativetimeandsubsequentcomplications.
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34. THE SAFETY OF THE INTRAOPERATIVE SACRIFICE OF THE DEEP CEREBRAL VEINSJ.McComb,MD;LaurenceDavidson,MD(NationalNavalMedicalCtr,MD)INTRODUCTION: Theeffectofsurgicallyligatingthedeepcerebralveinsisoftenthoughttobeofsignificantrisk.Thatconcernandthepaucityofinformationonsurgeryofthedeepvenoussystemconfoundsurgicaldecisionmakingwhenoperationsinvolvemanipulationofthedeepcerebralveins.METHODS: Aretrospectivereview,coveringtheperiodfrom1997to2009,wasundertakentoanalyzeourownclinicalexperiencewithintra-operativelysacrificingdeepcerebralveins.Thiswascombinedwithanextensivereviewoftheavailableliteratureonthecomplicationsofsacrificingsuchveins.RESULTS: Ourseriesconsistedof29casesofposteriorinter-hemisphericretro-callosalapproachforresectionofpinealregionandposteriorfossalesionsinchildren.Intra-operatively,deepcerebralveinsweresacrificedin3patientswhileasinglebridgingveinwasoccludedanddividedin6and2suchveinsinanother.Innocasewastheresacrificeofbothsuperficialanddeepveins.Nopatientdevelopedradiographicevidenceofvenousinfarction.Ourliteraturesearchyieldedapaucityofvenousinfarctssecondarytosacrificeofdeepcerebralveins.CONCLUSIONS: Robustexperimentalstudiesandlimitedclinicalexperienceindicatethatocclusionofoneorseveraldeepveinsisgenerallysafe.
35. PROTEIN PROFILING OF DIFFUSE INTRINSIC PONTINE GLIOMA TUMOR TISSUE: A COMPARATIVE ANALYSIS**AmandaMuhsSaratsis,MD;KendallSnyder;JordanHall;MadhuriKambhampati;SrideviYadavilli,PhD;JenniferPerez,BA;SureshMagge,MD;JavadNazarian,PhD(Arlington,VA)INTRODUCTION: DiffuseIntrinsicPontineGlioma(DIPG)isarare,highlymorbidformofpediatricbrainstemgliomaforwhichmolecularcharacterizationislimited.Comparativeproteomicanalysishasemergedasavaluabletoolforunderstandingtumorbiology.WepreviouslygeneratedproteinprofilesofCSFandformalinfixedtumorspecimensfromDIPGpatients.Here,wereportthecomprehensiveproteomeof50frozentissuespecimens,includingDIPGtumor(n=17),normalbrainstem(n=17),andotherpediatricbraintumors(n=16).METHODS: Tissuewascollectedintraoperativelyorpost-mortem.Extractedtotalproteinwasresolvedusing1DSDS-PAGE,in-geltrypticdigestionandMS/MSquantitativeproteomicanalysisusingLTQ-Orbitrap-XL.IsolatedpeptideswereidentifiedusingtheSequestalgorithmintheBioworksbrowseragainsttheUniprotHumandatabase.ComparativeanalysiswasperformedwithProteoIQandIngenuityPathwayAnalysis(IPA)software.RESULTS: Comprehensiveprofilingidentified2,305tissueproteins,50uniquetoDIPGtumortissue,withnosignificantdifferenceinthenumberofproteinsdetectedinpostmortemvs.intraoperativetumorspecimens(average=1102,SD=153).2,160proteinsshoweddifferentialexpression(foldchange<2or<-2)inDIPGtumorcomparedtonormalbraintissuefromthesamepatient;763comparedtoothertumortypes.67%ofpreviouslycharacterizedDIPGCSFproteinsweredetectedintheDIPGtumortissueproteome.CONCLUSION: WegeneratedthefirstcomprehensiveproteinprofileofDIPGfrozentumortissue,demonstratingnosignificantdegradationinproteinsobtainedpostmortem.Tissuevalidationandcomparisontogeneticprofilesareunderway.ProteomicanalysisoffersasystematicapproachtounderstandingDIPGtumorbiology.
36. BRAF-TARGETED THERAPEUTICS IN LOW-GRADE GLIOMASShih-ShanLang,MD;AngelaSievert,MD,MPH;KatieBoucher,BS;PhillipStorm,MD;AdamResnick,PhD(Philadelphia,PA)INTRODUCTION: Withlimitedtreatmentoptionsfordisseminatedorprogressivepediatricgliomas,thereisacriticalneedforeffectivetargetedtherapeutics.ActivatedBRAFmutationsareahallmarkofpediatricgliomasandtheKIAA1549-BRAFfusionmutationcharacterizesmostlow-gradegliomas.Thiskeygeneticeventhassignificantlyadvancedtheestablishmentoftargetedtreatmentsforgliomas.METHODS: Astherearenoestablishedpediatriclow-gradegliomacelllinesharboringtheKIAA1549-BRAFfusiongene,weengineeredavarietyofstablyexpressingBRAF-fusioncelllines.WeevaluatedthecellularandbiochemicaltargetingoftheMAPK(mitogen-activatedproteinkinase)signalingcascadeinthesecelllines.RESULTS: TheKIAA1549-BRAFfusionactivatestheMAPKsignalingcascadeandissufficientformalignantcellulartransformationandmousetumorformation.However,cellsexpressingKIAA1549-BRAFfusiondisplayincreasedparadoxicalactivationanddrugresistanceinresponsetofirstgenerationBRAF-specificinhibitors.InthepresenceoffirstgenerationBRAF-specificinhibitors,KIAA1549-BRAFfusiondisplayincreasedcellularproliferation,malignantcelltransformation,andacceleratedmousetumorgrowth.ResistancetotheseBRAFinhibitorsismediatedthroughaMAPKRAFinteractionthatisspecifictoandoccursonlywiththeKIAA1549-BRAFfusion.Incontrast,treatmentwithsecond-generationBRAFinhibitorsresultsincellularinhibitionoftheMAPKpathway,decreasedproliferation,anddecreasedmalignantcelltransformationcapacity.CONCLUSIONS: OurdevelopmentofpediatricgliomamodelstostudycellsignalingpathwayinteractionsofBRAFinhibitorsisfundamentalinprovidingtherationaleforclinicaltrials.Ourresultssupporttheestablishmentofselect,targetedtreatmentapproachesforchildrenafflictedwithBRAF-alteredgliomas.
37. NEO-ADJUVANT CHEMOTHERAPY IMPROVES SURVIVAL FOR INFANTS WITH EPENDYMOMA: PRELIMINARY RESULTS OF ST. JUDE YOUNG CHILDREN (SJYC07) TRIALFrederickA.Boop,MD,FAANS,FACS;PaulKlimo,MD,MPH;KarenWright,MD;AmarGajjar,MD;THassall,MD;DBowers,MD;JCrawford,MD;AtmanPai,MD;ThomasMerchant,DO;DavidEllison,MD;FrederickBoop,MD(Memphis,TN)INTRODUCTION: Age<3yearsandanaplastichistologicfeaturesarepoorpredictorsofsurvivalinchildrenwithependymomas.Five-yeareventfreesurvivalis<65%.Weprospectivelyexaminetheeffectofneo-adjuvantchemotherapy(CT)followedbyradicalsurgery,focalradiotherapy(RT)andmetronomicoraladjuvantCTonsurvivaloutcomes.METHODS: Twenty-twopatients<3yearsofagewithependymomawereenrolledonSJYC07betweenDecember2007andMarch2012.Treatmentincluded4identicalcyclesofinductionCTincludingMethotrexate,Cyclophosphamide,Cisplatin,andVincristine,followedbyfocalRT(54Gy)and6monthsoforalCT.RESULTS: Patientsincluded8femalesand14males(medianage21months).Therewere16grosstotal,5nearand1subtotalresections.Fourteenpatientshadanaplastichistologicfeatures.Seventumorsweremidlinefourthventricle,11CP-angleand4supratentorial.SpineMRIandCSFcytology(whenobtained)werenegativeformetastases.Atmeanfollow-upof24months(5-51),onepatientdevelopedspinalmetastasesafter3monthsoforalCT.Twopatientsareonactivetherapy.Onepatientexperiencedaseriousadverseeventunrelatedtochemotherapy.Surgicalcomplicationspre-treatmentincludedGradeIVhearingloss(n=1),persistentataxia(n=2),hemiparesis(n=1),CNVIandVIIpalsies(n=3)andswallowingdysfunction(n=6).CONCLUSIONS: Thesepreliminaryresultssuggestthatneo-adjuvantchemotherapy(1)iswelltoleratedinchildrenwithependymoma<3years,(2)reducestumorvascularityallowingsaferandmoreaggressivetumorresectionand(3)mayimprovesurvivalascomparedtoresection/radiationalone.
WITHDRAWN
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38. ROLE OF BONE MARROW DERIVED CELLS IN THE TUMOR MICROENVIRONMENT OF MEDULLOBLASTOMA**CaitlinElizabethHoffman,MD;KarenBadal,MD;PrajwalRajappa,MD;YujieHuang,PhD;JacquelineBromberg,MD,PhD;DavidLyden,MD,PhD;JeffreyGreenfield,MD,PhD(NewYork,NY)INTRODUCTION: Currenttherapeuticstrategiesdonotuniversallyresultindiseasecontrolinmedulloblastoma.Definingmechanismsofprogressionmaythereforeleadtomoreeffectivetherapeuticapproaches.Bonemarrow-derivedcells(BMDCs)haverecentlybeenshowntobeintegraltothemicroenvironmentofsystemicmetastatictumors.BMDCrecruitmentfactorsareoverexpressedinmedulloblastoma,buttheroleofthesecellsinthemedulloblastomamicroenvironmenthasnotbeenexplored.WethereforehypothesizedthatrecruitmentofBMDCstothemicroenvironmentmayplayaroleinmedulloblastomaprogression.METHODS: CirculatingBMDCsweremeasuredduringtumorprogressioninmousemedulloblastomamodelsviaflowcytometry.MouseandhumantumorsectionswerestainedtoevaluateBMDCrecruitment,neovascularization,andinvasivenessduringtumorgrowth.TheJak2inhibitor,AZD1480,wasusedtoblockBMDCrecruitment,andtumorgrowth,neovascularization,andinvasivenessweremeasured.EffectsofAZD1480ontumorversusBMDCproliferationwerecontrolled.RESULTS: BMDCswereupregulatedwithinthecirculationandthetumormicroenvironmentinmousemodelsofmedulloblastoma,andwerefoundatthetumorborderinhumanmedulloblastoma.TreatmentwithAZD1480resultedindecreasedcirculatingBMDCsanddecreasedBMDCrecruitmenttothemicroenvironment.TumorgrowthwasalteredbyAZD1480invivo,withdecreasednecrosis,neovascularization,andinvasiveness.TherewasnoeffectofAZD1480ontumorcellgrowthinvitro.CONCLUSIONS: BMDCsarerecruitedtothemicroenvironmentinmedulloblastoma.Inhibitionofthisrecruitmentleadstoalteredtumorgrowthwithoutdirectlyeffectingtumorcellproliferation.ThisindicatesaroleforBMDCsinthesupportofthemedulloblastomamicroenvironment,regulatingdiseaseprogressionthroughatumorcell-independentmechanism.
39. PSEUDOPROGRESSION OF LOW GRADE GLIOMAS AFTER RADIOTHERAPYRobertPartlowNaftel,MD;MelvinDeutsch,MD;ReginaJakacki,MD;IanPollack,MD(Pittsburgh,PA)INTRODUCTION: Increasingenhancementandmasseffectfollowingradiationtherapyinpatientswithlow-gradegliomas(LGG)canbemistakenfortumorprogressionand/ormalignantdegeneration.Differentiatingthispseudoprogressionfromtrueprogressionisnecessarytodeterminetheneedforalternativetherapy.Thisstudyinvestigatestheincidenceandtimetablepseudoprogressionafterradiotherapy(RT).METHODS: RetrospectivechartreviewwasperformedonchildrentreatedwithRTforLGGattheChildren’sHospitalofPittsburghNeuro-Oncologyprogramwithatleast1yearoffollow-up.RESULTS: Twenty-ninechildren,medianage12,underwentRT(externalbeam-21,gammaknife-6).Histologiesincludedjuvenilepilocyticastrocytoma(20/29),LGG(5/29),andradiologicdiagnosisofLGG(4/29).Seventeenpatientsdevelopedincreasedenhancementand/ormasseffectfollowingRTwithamediantimetomaximumtumorenlargementof6months,witharangeof4monthsupto4.7years.Tenchildrenweresymptomaticandtreatedwithsteroids(n=10)and/oravastin(n=3).Threechildrenwereoperatedupon,2forcystfenestration,andonefordebulkingafterconcernfortrueprogression;however,pathologyshowedtreatmenteffect:radiationnecrosiswithscatteredjuvenilepilocyticastrocytomatumorcells.Inall17cases,thetumoreventuallydecreasedinsizewithoutadditionalantitumortherapy.Withamedianfollow-upof4.8years(range1.0-12.4years),allpatientsremainaliveandprogressionfree.CONCLUSIONS: TumorpseudoprogressionwasseeninoverhalfofpatientswithLGG,occurringaslongas4.7yearsafterradiation.Radiotherapywasuniversallyeffectiveinthispopulationwithoutanyevidenceoftrueprogression.
40. SYSTEMATIC REVIEW OF THE RESULTS OF SURGERY AND RADIOTHERAPY ON TUMOR CONTROL FOR PEDIATRIC CRANIOPHARYNGIOMA**AaronJohnClark,MD;TeneCage,MD;DerickAranda,MD;AndrewParsa,MD,PhD;PeterSun,MD;KurtisAuguste,MD;NalinGupta,MD,PhD(SanFrancisco,CA)INTRODUCTION: Craniopharyngiomasareraretumorswithbimodalincidenceinthepediatricandadultagegroups.Treatmentstrategiesrangefromaggressiveresectiontoplannedlimitedresectioncombinedwithadjuvanttherapies.Currentlythereisnoconsensusforstandardofcareforpediatriccraniopharyngioma.METHODS: Weperformedasystematicreviewofthepublishedliteratureonpediatriccraniopharyngioma.Patientsweregroupedbasedonextentofresectionintogrosstotalresection,subtotalresection,andbiopsyprocedures.Thesegroupswerecomparedwithrespecttotumorcontrol.Chisquarewasusedtocompareratesofrecurrence.Kaplan-Meierwasusedtogenerateprogressionfreesurvivalestimates.Coxproportionalhazardmodelingwasusedtoevaluateriskofprogression.Eachextentofresectiongroupwasalsosubdividedbasedonadjuvanttherapyandcompared.RESULTS: Atotalof109studiesdescribedextentofresectionresultinginacohortof531patients.Recurrencedatawereavailablefor377patients.Therewasnodifferenceinone-yearorfive-yearprogressionfreesurvival(PFS)betweenthegroupswhounderwentgrosstotalresection(GTR)andsubtotalresection(STR)combinedwithradiation(XRT)(log-rank;p=0.76;1-yearPFS89vs84%;5-yearPFS77vs73%,respectively).One-yearPFSwas84%forSTR+XRTcomparedto76%forSTRalonewhilefive-yearPFSwas73%forSTR+XRTcomparedto43%forSTRalone(log-rank;p=0.003).CONCLUSIONS: Althoughtherearelimitationsofasystematicreviewofretrospectivedata,ourresultssuggestthatSTR+XRTofpediatriccraniopharyngiomaisassociatedwithsimilarratesoftumorcontrolasGTR.
41. EFFECT OF SURGICAL DEBULKING ON POST-OPERATIVE CEREBELLAR MUTISMAnthonyMyint;YasserJeelani,MD;JessicaAshford,MS;StephanieDaSilva,BA;J.GordonMcComb,MD;MarkKrieger,MD(SanMarino,CA)INTRODUCTION: Cerebellarmutismsyndrome(CMS)isanestablishedcomplicationofposteriorfossasurgeryinchildren.Ourstudyinvestigatesassociationsbetweenchoiceofsurgicaldebridingmethod(ultrasonicaspiration,microdissection,ormyriad)andCMSdevelopment.WealsoinvestigatepossibleriskfactorsassociatedwithCMS.METHODS: AnIRB-approvedretrospectivereviewwasperformedonallpatientswhounderwentposteriorfossatumorresectionatourinstitutionbetween2005and2012.Patientcharts,radiographicstudies,andpatient-evaluationsbyanonsitespeechpathologistwerereviewed.Patientsyoungerthan2yearsorwithsignificantpremorbidneurologicaldeficitswereexcludedfromthestudyduetodifficultyinassessingspeech.RESULTS: Ofthe86patientsmeetingtheabovecriteria,12(14%)hadpost-operativemutism.Averageageofonsetwas8years(range2.5-18.8).Usingchi-squareindependencetesting,thefollowingrisk-factorswerenotfoundtobesignificantlyassociatedwithmutism:pre-operativehydrocephalus,durationofsymptomspriortosurgery,choiceoftumor-debulkingmethod,vermiantumorlocation,tumortype,andprolongedpost-operativeintubation.Ethnicityshowedborderlinesignificance(p=0.052).Incontrast,ageinthe5to10yearrange,tumorlocationintherightcerebellarhemisphere,andinvasivetumor(necessitatingsubtotalresection)werefoundtobesignificantlyassociatedwithCMS.CONCLUSIONS: Ourstudysuggeststhatageof5to10yearsattimeofsurgery,tumorlocationintherightcerebellarhemisphere,andsubtotalresectionallincreaseriskofpost-operativemutism.Interestingly,ourresultsdidnotshowacorrelationbetweenhistology,vermianinvolvement,andresectiontechniqueinthedevelopmentofCMS.
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42. FLUORESCENCE-GUIDED RESECTION OF PEDIATRIC CNS NEOPLASMS WITH THE USE OF NOVEL, SAPOSIN C-DIOLEOYLPHOSPHATIDYLSERINE (SAPC-DOPS) NANOVESICLESLaurenRoseOstling,MD;XiaoyangQi,PhD;CharlesStevenson,MD(Cincinnati,OH)INTRODUCTION: Real-time,fluorescence-guidedresectionofmalignantgliomasutilizing5-ALAisbeingincreasinglyemployedinadultpatients,withinitialdatasuggestinggreaterextentofresection,and,improvedsurvivaladvantage.However,5-ALAhasinherentlimitationsasamolecularcontrastagent,includingrelativenonspecificity,weakfluorescence,andpooraffinityfornonenhancingtumors.Developmentofsuperiorcompounds,capableoflabelingabroadspectrumoftumors,willimprovetheclinicalutilityoffluorescence-guidedresection.Wehaveengineeredanon-toxic,near-infraredfluorescingglycoproteinnanovesicle,SapC-DOPS,thatcrossestheblood-brainbarrierandbindsaberrantphosphatidylserineresiduesonneoplasticcells.METHODS: Toestablishrelativelabelingsensitivityandspecificity,tissuesectionsofmultiplepediatricintracranialneoplasmswerestainedwithSapC-DOPS.TailveininjectionsofSapC-DOPSwerethenperformedinmiceharboringglioblastomaintracranialxenografts.Craniotomywasperformedinthesemice,andfluorescencemicroscopyusedtovisualizeandguidetumorresection.Histologicalanalysisofresectedspecimenswasperformedtocorrelatesensitivityandspecificityoftumorlabeling.RESULTS: SapC-DOPSwasshowntospecificallybindglioblastomacellsversusnon-neoplastictissuebothinvitroandinvivo.Invivo,tumorlabelingwasrobustandspecific,withbrightsignalenablingtumorresectionsunderreal-timefluorescencemicroscopy,andnodetectablefluorescenceofadjacentbrainparenchyma.CONCLUSIONS: SapC-DOPSisanon-toxicmolecularcontrastagentthatspecificallybindsneoplasticcells.Ithasdemonstratedexcellentsensitivityandspecificityforhigh-gradegliomas,withcurrentstudiesexaminingitsaffinityforadditionalbraintumors,includinglow-gradelesions.Givenitspotentialapplicability,SapC-DOPSmaybesuperiortocompoundscurrentlyusedinfluorescent-guidedresectionsofintracranialneoplasms.
43. PROGRESSION OF CRANIOPHARYNGIOMA FOLLOWING CONFORMAL RADIATIONPaulKlimoJr.,MD;FrederickBoop,MD;KyleGabrick,BS;ThomasMerchant,MD;RobertSanford,MD(Memphis,TN)INTRODUCTION: Managementofpatientswithcraniopharyngiomacontinuestobecontroversial.Someadvocateaggressivesurgery.Others,includingourselves,favorlesssurgeryfollowedbyradiationforresidualdisease.METHODS: RetrospectivereviewofallpatientstreatedwithconformalradiotherapyfollowingsurgeryforcraniopharyngiomatreatedatSt.JudeChildren’sHospital.Treatmentfailurewasdefinedassolidorcystictumorprogressionrequiringintervention.RESULTS: Eighty-eightchildren(medianage8.5yrs,range3.2-17.6yrs)receivedconformalorintensity-modulatedradiationtherapybetween1998and2009.Therewere14(16%)childrenthathadprogressivedisease.Timetoprogressionfollowingradiationwas49.7months.Therewere4(0.4%)deaths,3relatedtoprogressivedisease(1malignantdisease,2secondarytotreatment)1secondarytosepsisinachildwithstableresidualdisease.Ofthe14tumorprogressionspostradiation9developednewcystsand5weresolidtumorprogression.Twoofthe5solidprogressionsweresuccessfullytreatedwithgrosstotalresectionandonewithsubtotalresectionandgammaknife.Ofthe9cysticprogressions,6weresuccessfullytreatedwithOmmayareservoirandmultipleaspirationswith38-monthaveragefollowup,3weretreatedwithsubtotaltumor+cystresectionwith32-monthfollowup.Asofthisdatenonehaveshownsolidtumorprogression.CONCLUSIONS: Cysticprogressionafterconformalradiationmaynotindicatetruetumorprogression.Managementofthecystalonemaysignificantlypalliatethesechildrenwithlowmorbidity.Solidtumorprogressioncanbesuccessfullymanagedwithgrosstotalresection.
44. EVALUATION OF A NEW STAGING SYSTEM FOR JUVENILE NASOPHARYNGEAL ANGIOFIBROMAS (JNA)KimberlyAnneFoster,MD;CarlSnyderman,MD;EricWang,MD;CarlosPinheiro,MD;HPant,MD;JuanFernandez-Miranda,MD;PaulGardner,MD;ElizabethTyler-Kabara,MD,PhD(Pittsburgh,PA)INTRODUCTION: JNAisabenignvasculartumorthatbehavesinalocallyaggressivemannerwithassociatedintracranialextension.Multiplestagingsystemsexist,butdonotaccountforrouteofintracranialextensionortumorvascularity.METHODS: WeretrospectivelyreviewedJNAsatourinstitutiontoevaluateprognosticfactorsforrecurrenceanddevelopanewstagingsystem.RESULTS: FortypatientsunderwentsurgicalresectionofJNA;allweremalewithaverageageof14years.All(100%)underwentpreoperativeembolization.Meanfollow-upwas50months;11patientshadevidenceofrecurrentdiseasewith6requiringrepeatintervention.TheUPMCstagingsystemwasdevisedbasedonanatomicalinvolvementoftumorandvascularityfollowingembolization.StageI:nasalcavity,medialpterygopalatinefossa.StageII:paranasalsinuses,lateralpterygopalatinefossaandnoresidualvascularity.StageIII:skullbaseerosion,orbit,infratemporalfossaandnoresidualvascularity.StageIV:skullbaseerosion,orbit,infratemporalfossawithresidualvascularity.StageV:intracranialextensionwithresidualvascularity(V-M:medialextension;V-L:lateralextension).BloodlossforUPMCstagesIV/V(2240+/-2272ml)wassignificantlygreaterthanUPMCstagesI/II/III(318+/-178ml)(p=0.001).NopatientsintheUPMCStageI/II(n=8)showedevidenceofrecurrenceorrequiredrepeatsurgery.Nopatientrequiredadjuvantradiation.CONCLUSIONS: GoalsoftreatmentofJNAarecompletesurgicalresectionandavoidanceofradiationtherapy.TheUPMCStagingSystemincorporatesprognosticfactorsnotaddressedbypriorsystems:routeofextensionandresidualvascularityfollowingembolization.Routeofextensionisanimportantconsiderationinselectingoptimalsurgicalapproach.
45. DECISION ANALYSIS OF TREATMENT OPTIONS FOR PEDIATRIC CRANIOPHARYNGIOMASLawrenceDaniels,MD;ZarinaS.Ali,MD;RobertBailey,MD;JohnLee,MD;PhillipStorm,MD;ShermanStein,MD;GregoryHeuer,MD,PhD(Philadelphia,PA)INTRODUCTION: Withadvancementsinthesupportivecareandradiationtreatmentforchildrenwithcraniopharyngioma,outcomeassessmentsarefocusingonqualityofliferatherthanmortality.METHODS: Wedevelopedadecisionanalyticmodeltoevaluateoutcomesoffoursurgicalapproachestocraniopharyngiomainchildren,including:attemptedgrosstotalexcision,plannedsubtotalremovalplusradiotherapy,biopsyplusradiotherapy,andendoscopicexcisionsofallkinds.Themodelprojectsquality-adjustedlifeyears(QALYs)fromdataderivedfromacriticalreviewofpublishedreports.Pooleddatawereusedtocalculatetheincidence,relativerisksandsummaryoutcomesforthefourmanagementstrategies.RESULTS: UsingthesevaluesinaMonteCarlosimulationofaseriesofvirtualrandomizedclinicaltrialsyieldedQALYsat5-yearfollow-upof2.3+/-0.1forattemptedgrosstotalexcision,2.9+/-0.2forplannedsubtotalremovalplusradiotherapy,3.9+/-0.2forbiopsyplusradiotherapy,and3.7+/-0.2forendoscopicresection(F=17,150,p<0.001).Similarly,QALYsat10-yearfollow-upwere4.5+/-0.2forattemptedgrosstotalexcision,5.7+/-0.5forplannedsubtotalremovalplusradiotherapy,7.8+/-0.5forbiopsyplusradiotherapy(F=6,173,p<0.001).Follow-updataattenyearsislackingforendoscopiccases.CONCLUSIONS: Biopsywithsubsequentradiotherapyisthepreferredapproachwithrespecttoimprovedoverallqualityoflife.Endoscopicresectionmayalsoprovidesimilaroutcome,butlong-termdataarecurrentlylimited.Thismeta-analysisisinherentlylimitedbyaggregatingtheretrospectiveexperienceofmultiplecenterswithdifferentsurgicalexperiences.
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46. PSEUDOPROGRESSION IN THE PEDIATRIC BRAIN TUMORS**ChesterKossmanYarbrough,MD;AravindSomasundaram,BS;JeffreyLeonard,MD(St.Louis,MO)INTRODUCTION: Treatmentofpediatricbraintumorsoftenemploysamultimodalitystrategyincludingsurgery,radiation,andchemotherapy.Inadultgliomapatients,developmentoftreatment-inducedcontrastenhancementsoonafterchemotherapyandradiationhasbeenwell-documented.Thisphenomenonhasnotbeenstudiedindepthinthepediatricpopulation.METHODS: Patientsundergoinginitialresectionofpediatriclowandhighgradeprimarybraintumorsbetween2004and2012wereidentifiedviaourinstitutionalneuro-oncologydatabase.Treatmentsandradiographicimageswerereviewed,andthepatientswhosufferedfrompseudoprogressionwereidentifiedforfurtherstudy.Datawasanalyzedseparatelyforpatientsharboringlow(WHOIandII)andhigh(WHOIIIandIV)gradetumors.RESULTS: 4.4%(6/137)oflowgradeand12.5%(7/56)ofhighgradepatientsexhibitedpseudoprogression.Radiographicchangesoccurred3.3monthsand4.3monthsafterradiationtreatmentandresolvedafter10.1and10.5monthsinlowandhighgradepatients,respectively.CONCLUSIONS: Pseudoprogressionisanimportantphenomenontorecognizeinpediatricpatientsundergoingchemoradiationforlowandhighgradetumors.Theredoesnotappeartobeasignificantdifferenceinbehaviorofpseudoprogressionbetweenlowandhighgradepatients,providedthatsimilarradiationparadigmsareused.Thelowerincidenceofpseudoprogressioninlowgradepatientsislikelyduetolessutilizationofadjuvanttherapiesinthosepatients.
47. DOES THE PRESENCE OR DEVELOPMENT OF HYDROCEPHALUS AFFECT THE PROGNOSIS FOR DIFFUSE INTRINSIC PONTINE GLIOMA?IfeanyiDavidNwokeabia;JohnGrimm,MD;IraBowen,BA;YasserJeelani,MD;SaraGhayouri;StephanieDaSilva,MD;MarkKrieger,MD;J.GordonMcComb,MD(WashingtonDc,DC)INTRODUCTION: DiffuseIntrinsicPontineGliomas(DIPG)arehigh-gradetumorsthatarelocallyinfiltrative,andhaveauniformlypoorprognosisdespiteaggressivetherapy.DevelopmentofhydrocephalusinpatientswithDIPGiscommonbutlittleresearchexistscorrelatingtheincidenceandprogressionofhydrocephalustogeneraloutcomeinthesechildren.METHODS: InthisIRB-approvedstudy,41childrenwithDIPGfrom2000to2011wereretrospectivelyreviewed.SerialMRIsandCTswereevaluatedfordiseasecourseandpresenceofhydrocephalus.RESULTS: Theaverageagewas8.1yearsand26(61%)werefemale.Theaverageoverallsurvival(OS)ofthegroupwas11.3months.Childrenunder3yearsofagehadshorteraveragesurvivalthanolderchildren(5.2vs12months,p=0.05).33receivedradiationand27weretreatedwithchemotherapy.23patients(56%)hadhydrocephalus;9haditatpresentationand14developeditinadelayedfashion.TheaverageOSforpatientswithhydrocephalusatpresentationwas13.7monthsvs.11.8monthsforpatientswithouthydrocephalusatpresentation(p=0.52).Patientswhodevelopedhydrocephalusinadelayedfashion(mediandelay7.13months),hadamediansurvivalof8.7monthsfromthetimeoftreatmentofthehydrocephalus.CONCLUSIONS: ThepresenceofhydrocephalusatthetimeofdiagnosisofDIPGdidnotaffectprognosisinthisseries.Substantialsurvivalispossibleafterthepresentationofhydrocephalus;thisinformationshouldbeusefulindeterminingtheutilityoftreatingthehydrocephalusandincounselingpatientsandtheirfamilies.
48. MORBIDITY AND NEUROLOGICAL OUTCOMES FOLLOWING REPEAT SURGICAL RESECTION OF PEDIATRIC INTRAMEDULLARY TUMORS**RaheelAhmed,MD;ArnoldMenezes,MD(IowaCity,IA)INTRODUCTION: Managementofrecurrentorprogressiveintramedullarytumorsposessignificantchallengesgiventhepotentialmorbidityofsurgicalresectionandriskofsecondarydeformity.Moreover,therespectiverolesofchemotherapyandradiotherapyarenotwellestablished.Wereviewedourinstitutionalexperienceinmanagementofrecurrentpediatricintramedullarytumors,focusingonpatientswhounderwentrepeatsurgicalresection.METHODS: Caserecordsforpediatricpatients(<21yr),treatedatourinstitutionforIMSCTswereanalyzed.Patientdemographics,treatmentandoutcomevariableswereexamined.RESULTS: Ofatotalof55patients(<21yr)withpediatricIMSCTsidentifiedbetween1975and2010,15patients(27%)underwentrepeatsurgicalresection.Averageage(9yr)inthisgroupwasnotsignificantlydifferentfromtheremainderstudygroup(10yr).Lowgradehistologicalsubtypesweremorepredominantintherepeatsurgerygroup(p-value<0.01).Theproportionofpatientswhounderwentgrosstotalversussubtotalresectionwasnotsignificantlydifferentbetweenthetwogroups.Mediansurvivalwassignificantlylowerinrepeatsurgerygroup(median=10yr)ascomparedtosinglesurgerygroup(median=29yr;p-value<0.05).Similarly,patientsinrepeatsurgerygroupwheremorelikelytodemonstratedeclineinMcCormickfunctionalgradeovertheirclinicalcourse(p-value<0.01).CONCLUSIONS: Lowgradetumorscomprisethemajorityhistologicalsubtypeinpatientsundergoingrepeatsurgicalresection.Despitetheirbenignbiologicalbehavior,lowgradetumoroftenexhibitsignificantlongtermmorbiditysecondarytoprogressionorrecurrence.
49. GREATER EXTENT OF RESECTION IMPROVES PROGRESSION-FREE SURVIVAL IN CHILDREN WITH GANGLIOGLIOMAS: A VOLUMETRIC ANALYSISDevonH.Haydon,MD;JeffreyLeonard,MD(St.Louis,MO)INTRODUCTION: Gangliogliomasareindolenttumorsbutcanrecurwithvaryingfrequency.Althoughsomeconsiderextentofresection(EOR)apredictorofclinicaloutcome,earlierstudiesassessEORbyanall-or-nothing,completevs.incompleteclassification.ThisstudyusesavolumetricanalysistoidentifyaspecificgangliogliomaEORthresholdwhichpredictsimprovedprogression-freesurvival(PFS)inchildren.METHODS: ClinicalrecordswereretrospectivelyreviewedfromSt.LouisChildren’sHospital.Patientswereincludediftheywere<20yearsatdiagnosisofaWHOgradeIganglioglioma,receivedsurgeryalone,andhadaccompanyingvolumetricimagingandsurvivaldata.RESULTS: Twenty-threechildren(11males,12females)wereidentifiedwithameanageatdiagnosisof13years.Thetemporallobewasmostfrequentlyinvolved(15cases).Preoperativetumorvolumewas9.3cm3(range0.3–61.1).MeanEORwas95.6%(range64.7-100)whilemeanresidualtumorvolumewas0.5cm3(range0–3.7).Fivetumorsrecurredanaverageof14.2monthsfollowingdiagnosis(range5.3–27.7).ImprovedPFSwasobservedforlesionswith≥94%EOR(p=0.027).Residualtumorvolume<1.6cm3wasalsoassociatedwithprolongedPFS(p<0.001).Meandurationoffollow-upwas31.3months(range4.5–104.7).CONCLUSIONS: EOR≥94%andresidualtumorvolume<1.6cm3areassociatedwithimprovedPFSinchildrenwithgangliogliomas.Thesedataindicatethatevenathorough,subtotalresectioncanimproveclinicaloutcome.Cytoreductivesurgeryshouldbeofferedfornewlydiagnosedgangliogliomasinchildrenwhensafelyfeasible.
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50. QUALITY MEASURES FOR THE MANAGEMENT OF HYDROCEPHALUS: CONCEPTS, SIMULATIONS, AND PRELIMINARY FIELD TESTINGJosephH.PiattJr.,MD;SpencerBarton;JeffreyCampbell,MD(MerionStation,PA)INTRODUCTION: Wedefineandexaminethepropertiesof2new,practice-basedqualitymeasuresforthemanagementofhydrocephalus.METHODS: TheSurgicalActivityRate[SAR]isdefinedasthenumberofoperationsforhydrocephalusperformedinaneurosurgicalpracticeoverthecourseofayeardividedbythenumberofpatientswithhydrocephalusseeninfollowupduringthatyear.TheRevisionQuotient[RQ]isdefinedasthenumberofrevisionoperationsperformedinaneurosurgicalpracticeinthecourseofayeardividedbythenumberofinitialoperationsforpatientswithnewdiagnosesofhydrocephalus.Employingpublishedshuntsurvivaldata,MonteCarlosimulationswereconductedtoillustratethepropertiesoftheSARandtheRQ.EmployingdatafromtheKids’InpatientDatabase[KID]for2009,RQswerecalculatedforhospitalswithmorethan10admissionsforinitialCSFshuntinsertions.RESULTS: Duringthegrowthphaseofasimulatedpractice,theSARapproacheditssteadystatevalueearlierthantheRQ.Bothmeasuresweresensitivetodoublingorhalvingofmonthlyfailurerates.Inthe2009KID117hospitalaccountedformorethan10initialshuntinsertions.Theweightedmean[SD]RQwas1.79[0.69].Amonghospitalswith50ormoreinitialshuntinsertions,theRQrangedbetween0.71and3.65.CONCLUSIONS: TheSARandtheRQhaveattractivequalitativefeaturesaspractice-basedqualitymeasures.TheRQexhibitsclinicallymeaningfulinterhospitalvariation.TheSARandtheRQmeritprospectivefieldtesting.
51. FOURTH VENTRICULAR SHUNT SURVIVAL COMPARING PARIETAL STEREOTACTIC ENDOSCOPIC TRANSTENTORIAL AND SUBOCCIPITAL APPROACHES**SarahTamaraGarber,MD;FrankBishop,MD;DouglasBrockmeyer,MD;JayRiva-Cambrin,MD(SaltLakeCity,UT)INTRODUCTION: Traditionalmanagementofloculatedfourthventricularhydrocephalusconsistsofsuboccipitalfourthventricularshunt(FVS)placement.Alternatively,aparietalstereotactically-guidedendoscopictranstentorialapproachtothefourthventriclecanbeused.Thisstudycomparestheshuntsurvivalandrevisionratesbetweenthesetwoapproaches.METHODS: Weretrospectivelyreviewed29consecutivepatientswhounderwentFVSplacementfromJanuary1st,1998throughDecember31,2011eitherviathesuboccipital(SO)orparietalstereotacticendoscopictranstentorialapproach(PSET).TheprimarystudyvariableconsistedoftheoriginalFVSplacementaswellasthefirstcross-overproceduretotheotherapproachifperformed.Ourprimaryoutcomewasshuntfailuredefinedasthenumberofdaystofirstshuntrevisionorremoval(obstructionorinfection).RESULTS: TherewasastatisticallysignificantdifferenceintimetofailurewiththePSETshuntslastinganaverageof901daysvs.122daysfortheSOtechnique(p=.04).Therewasalsoasignificantdifferenceintherateofcrossoverwith1PSETtoSOshunt(5.6%)and5SOtoPSETshunts(45.5%).Theetiologyoffourthventricularhydrocephalusandtheneurosurgeonperformingtheprocedurewerenotstatisticallysignificantinthisstudy.CONCLUSIONS: Parietalstereotactically-guidedendoscopictranstentorialFVSplacementresultedinsignificantlylongershuntsurvivalsandlowerrevisionratesthanthetraditionalsuboccipitalapproach,despiteahigherrateofcrossoverfrompreviouslyfailedshuntingprocedures.PSETshuntplacementmaybeconsideredanoptionforpatientswithloculatedfourthventricularhydrocephalus,particularlywhenshuntplacementviathestandardsuboccipitalapproachfails.
52. VENTRICULOMEGALY DIAGNOSED ON FETAL MRI AND THE RISK OF POST-NATAL HYDROCEPHALUSMatthewKole;JenniferWilliams,MD;AngelKrueger;DeboraYbarra;WilliamWhitehead,MD;ChristopherCassady,MD;RobertBollo,MD(Houston,TX)INTRODUCTION: VentriculomegalyisamongthemostcommonanomaliesdiagnosedbyfetalMRI.Limiteddatasuggestssevereventriculomegalyisassociatedwithahighriskofpost-natalhydrocephalus,howeverthespecificnatureofthiscorrelationremainsunclear.METHODS: Weperformedaretrospectivecohortanalysisof81maternal-fetaldyadsdiagnosedwithventriculomegalybyfetalMRIoveraten-yearperiod[2003-2012].Patientswereincludedifatleastonelateralventricleatrialdiameter[AD]measured≥10mm(mean15mm)and≥3monthsofpost-natalfollow-updatawasavailable(mean26months).Weassessedtherelationshipbetweengestationalage,fetalsex,ADforeachlateralventricle,thepresenceofotherCNSanomalies,andpost-natalhydrocephalusrequiringsurgicaltreatment.RESULTS: MeangestationalageatthetimeoffetalMRIwas27.3weeks.47fetuses(58%)weremale.In34cases(42%),noadditionalCNSanomalieswereidentified.Fifteencases(19%)developedpost-natalhydrocephalus.MeanADwas23±7mminthesecases,vs.14±4mminfetuseswhodidnotdevelophydrocephalus(p<0.001).Excludingpatientswithmyelomeningocele(n=26)andDandy-Walkermalformation(n=2),3%(1/29)ofpatientswithlargestAD<15mmunderwentsurgeryforhydrocephalus,comparedto65%(11/17)withoneAD≥20mmand86%(6/7)withoneAD≥30mm.CONCLUSIONS: SevereventriculomegalyonfetalMRI(oneAD≥20mm)appearsstronglyassociatedwithpost-natalhydrocephalus.Conversely,intheabsenceofspecificCNSanomalies,mildfetalventriculomegaly(AD<15mm)isnot.
53. ABNORMAL DEVELOPMENT OF NG2+PDGFRΑ+ NEURAL PROGENITOR CELLS CAUSES NEONATAL HYDROCEPHALUSTimothyW.Vogel,MD;CalvinCarter,BA;QihongZhang,PhD;TomMoninger,PhD;DanThedens,PhD;KimberlyKeppler-Noreuil,MD,PhD;DarrylNishimura,PhD;CharlesSearby,PhD;KevinBugge,BA;ArnoldMenezes,MD;ValSheffield,MD,PhD(St.Louis,MO)INTRODUCTION: Congenitalhydrocephalusisacommonneurologicaldisorderleadingtotheexpansionofthecerebralventriclesandisassociatedwithsignificantmorbidityandmortality.Themajorityofneonatalcasesareofunknownetiology.Identifyingmolecularmechanismsresponsibleforneonatalhydrocephalusanddevelopingnoveltreatmentmodalitiesarehighpriorities.METHODS: WeemployedahydrocephalicmousemodelofthehumanciliopathyBardet-BiedlSyndrome-(BBS)toidentifyaroleforneuralprogenitorcellsinthepathogenesisofneonatalhydrocephalus.WealsoidentifiedhumanBBSpatientswithknownBBSmutationswhohadventriculomegalysimilartothoseobservedintheBBSmousemodel.RESULTS: WefoundthathydrocephalusinthismousemodeliscausedbyaberrantPDGFRαsignaling,resultinginincreasedapoptosisandimpairedproliferationofNG2+PDGFRα+neuralprogenitorcells.ConditionalknockoutofBbs1inthisprogenitorcellpopulationleadtoneonatalhydrocephalusandconfirmedtheinvolvementofNG2+PDGFRα+progenitordevelopment.Hydrocephalusintheseconditionalknockoutmicedevelopedinthepresenceofnormalmotileciliachallengingtheconventionalviewthatmotileciliaarecrucialinthepathogenesisofhydrocephalus.TargetingthedefectivePDGFRαsignalingpathwaywithnovelagentsrescuedprogenitorcelldevelopmentresultinginreducedventricularvolumeandimprovedfunctionaloutcomes.CONCLUSIONS: Ourfindingsindicatethatabnormalitiesinasubsetofneuralprogenitorcellsplayacrucialroleinthepathogenesisofneonatalhydrocephalussimilartothoseseeninhumanpatients.Importantly,weidentifynoveltherapeutictargetsforalteringtheseverityofhydrocephalus.WealsoidentifyanovelroleforBBS1inmediatingthePDGFRαsignalingpathway.
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54. DECORIN REDUCES VENTRICULOMEGALY AND SUBARACHNOID FIBROSIS IN JUVENILE RATS WITH COMMUNICATING HYDROCEPHALUSJamesP.(Pat)McAllisterII,PhD;HannahBotfield,MS;AndersSkjolding,MD;AnaGonzalez,PhD;OsamaAbdullah,MS;MartinBerry,PhD;AnnLogan,PhD(SaltLakeCity,UT)INTRODUCTION: Subarachnoidfibrosis,especiallyinthebasalcisterns,oftencauseschroniccommunicatinghydrocephalus.Decorin,aTransformingGrowthFactor-betaantagonist,reducesscarringinbrainandspinalcordlesions;therefore,wehypothesizedthatDecorincouldhavetherapeuticpotentialinpediatriccommunicatinghydrocephalus.METHODS: Three-weekoldratsreceivedkaolininjectionsintothebasalcisternstoinducesubarachnoidfibrosisandcommunicatinghydrocephalus.Atthesametime,recombinanthumanDecorinorvehiclewereinfusedintothelateralventriclecontinuouslyfor14daysviaosmoticminipumps.MRIwasusedtoevaluateventricularvolumesat14daysandfibrosisandinflammationwascharacterizedwithimmunocytochemistry.RESULTS: Lamininandfibronectinimmunostainingdemonstratedthatfibrosiswasprevalentatthesiteofkaolininjectionsbutnowhereelseinhydrocephalicbrains.Decorinstainingwaslocalizedtotheependymathroughouttheventricularsystem,epithelialcellsofthechoroidplexus,andwithinthesubarachnoidspaces,confirmingthatitwasdistributedthroughouttheCSF.Hydrocephalicanimalswithorwithoutvehicleinfusionhadsignificantlyenlargedventriclescomparedtocontrols(p<0.05)andconspicuousfibrosisinthebasalcisterns.Ratsreceivingkaolin+Decorininfusionshadsignificantlyreducedventricularvolumes(p<0.05).CONCLUSIONS: TheseresultsstronglysuggestthatDecorinmayhavethepotentialtoameliorateventriculomegalybyreducingfibrosisinthesubarachnoidspaces,andthuscouldbeapromisingtherapeuticcandidatefortreatinghydrocephalus.
55. FRONTAL VERSUS PARIETAL CSF SHUNTS AND SHUNT SURVIVAL, AN HCRN STUDYWilliamE.Whitehead,MD,MPH,FAANS;AbhayaKulkarni,MD;JayRiva-Cambrin,MD;JohnWellons,MD;JamesDrake,MD;ThomasLuerssen,MD;JerryOakes,MD;MarionWalker,MD;JohnKestle,MD(Houston,TX)INTRODUCTION: Thereisconflictingdataintheliteratureregardingtheeffectshuntentrysitehasonshuntsurvival.Thestudyobjectivewastodetermineifventricularcatheterentrysite(frontalv.parietal)forfirst-timeCSFshuntinsertionsaffectsshuntsurvival.METHODS: Patientsfrom3prospective,multi-centeredtrialswithsimilarmethodologies(shuntdesigntrial,n=344;endoscopicshuntinsertiontrial,n=393;ultrasoundguidedshuntinsertionstudy,n=121)werecombinedandclassifiedbasedonventricularcatheterentrysite.Allpatientswerelessthan18yearsoldwithnewonsetofhydrocephalus.RESULTS: Threehundredshunts(35.0%)wereplacedwithafrontalapproach;550shunts(64.1%)wereplacedfromaparietalapproach.Datawasmissingin8patients(0.9%).Therewasnosignificantdifferencebetweenthe2groupswithrespecttoageandetiologyofhydrocephalus.Frontalshuntsresultedinaone-yearshuntsurvivalrateof70.6%andatwo-yearsurvivalrateof63.1%.Parietalshuntsresultedinaone-yearsurvivalrateof58.2%andatwo-yearsurvivalrateof45.7%(Mantel-HaenszelLogranktest,p<0.001).Mediansurvivaltimeforfrontalshuntswas3.09years(95%CI:2.27,3.90)andforparietalshuntswas1.64years(95%CI:1.21,2.08).Therewasnotasignificantdifferenceintherateofshuntinfection(frontal10.0%;parietal9.3%).CONCLUSIONS: Forfirst-timeshuntinsertionsthereappearstobeasurvivaladvantagewhenventricularcathetersareplacedusingafrontalapproach,butthestudydesigncannotaccountforallconfounders.Thesignificanceofthisfindingsupportsarandomizedtrial.
56. THE RISK FACTORS FOR AND THE INFLUENCE OF HYDROCEPHALUS ON NEUROLOGICAL OUTCOME IN CHILDREN BORN WITH AN ENCEPHALOCELEStephanieLouiseDaSilva;YasserJeelani,MD;AndrewYousef;MarkKrieger,MD;J.GordonMcComb,MD(LosAngeles,CA)INTRODUCTION: Thereisaknownassociationofhydrocephaluswithencephaloceles.Riskfactorsforhydrocephalusandtheneurologicaloutcomewerereviewedinourseriesofpatientsbornwithanencephalocele.METHODS: UnderIRBapproval,aretrospectiveanalysiswasundertakenofpatientstreatedforencephalocelesatasingleinstitutionbetween1994and2012.RESULTS: 70children(38female)wereidentified.Themedianageatpresentationwas2months.Meanfollow-upwas2.5years.Locationwasoccipital(35children)occipitoparietal(13),frontal(10),parietal(7),andbasal(5).Theaveragesizewas4cm(range0.5-23cm).Forty-sevencontainedneuraltissue.TeninfantspresentedatbirthwithCSFleakingfromtheencephalocele,withonebeinginfected.Sixpatientspresentedwithhydrocephaluswhile11developedhydrocephaluspost-operatively.Thefollowingfactorswerefoundtohaveastatisticallysignificantassociationwithhydrocephalus:presenceofneuraltissue(p=0.03),largersize(p=0.007),locationposteriortothecoronalsuture(p=0.03),andthepresenceofotherCNSanomalies(p=0.007).Fourteenhadseveredevelopmentaldelay,9moderate,and19mild;28patientswereneurologicallynormal.Encephalocelesofgreaterthan2cmdiameterandpresenceofhydrocephalushadahighincidenceofdevelopmentaldelay(n=34/49,p=0.02andn=17/17,p=0.0001,respectively).CONCLUSIONS: Theincidenceofhydrocephalusinchildrenbornwithencephalocelesisinfluencedbypresenceofneuraltissue,size,posteriorlocation,andthepresenceofotherassociatedCNSanomalies.Incontrasttothemodestlygoodneurologicaloutcomeinchildrenwithanencephalocelewithouthydrocephalus,thepresenceofhydrocephalusresultedinafarworseoutcome.
57. LIMITED SEQUENCE HEAD CT ANALYSIS FOR CHILDREN WITH SHUNTED HYDROCEPHALUS**JonathanA.Pindrik,MD;EdwardAhn,MD;AylinTekes,MD;ThierryHuisman,MD(Baltimore,MD)INTRODUCTION: Diagnosticheadcomputedtomography(CT)impartsrisksofradiationtoxicity.Childrenwithshuntedhydrocephalusexhibitincreasedriskofexposureduetothinnertorsos,immaturetissues,andfrequentscanning.TechniquestoreduceradiationtoxicityfromheadCTincludedecreasingthenumberofaxialslices.METHODS: Consistentsequencesof7axialsliceswereextractedfromheadCTscansofchildrenwithshuntedhydrocephalusbutnohistoryofintracranialmasslesions.Chronologicallydistinctscansofeachpatientwereblindly,retrospectivelyreviewedbytwopediatricradiologistsandonepediatricneurosurgeon.LimitedCTsequenceevaluationfocusedonadequacyofportrayingtheventricularsystem,caliber,andcatheter.ReviewersassessedtheoriginalheadCTscansofeachpatientover4monthslaterforcomparison.RESULTS: TwoserialheadCTscansfromeachof50patients(agerange0-17years;meanage5.5years)werereviewed.Theextractedlimitedsequencesofaxialslicesadequatelyportrayedtheventricularsysteminallcases.Theinaccuracyrateforassessingchangesinventricularcaliberbymajorityassessment(2outof3reviewers)wasbelow8.0%.Inaccuraciesinvolvedscansshowingdiminutivechangesinventricularsize.ThelimitedCTsequencesdisplayedtheventricularcatheterin91.7%ofscans.CONCLUSIONS: LimitedsequencesofaxialheadCTscansretainclinicalutilitywhilereducingradiationtoxicityinchildrenwithshuntedhydrocephalus.ThissequenceofaxialslicescanbeimplementedintoalowdoseheadCTprotocolindicatedforshuntedpediatricpatientsduringfollow-uporwithlowclinicalsuspicionofshuntmalfunction.
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58. SIGNIFICANT SHUNT OBSTRUCTION CAUSED BY PARENCHYMAL TISSUE SHEARING DURING VENTRICULAR CATHETER IMPLANTATION**JayantPrasannaMenon,MD;KathrynOlson;JonDunbar,BS(SanDiego,CA)INTRODUCTION: Proximalventricularshuntobstructionisthemostcommoncauseofshuntfailure.Short-termfailureisoftenattributedtochoroidplexusobstructionandlittleattentionhasbeengiventoobstructionassociatedwithcatheterplacement.UponinvitroexaminationofproximalcathetersofVPshunts,87%ofholesareobstructedimmediatelypost-insertion.METHODS: Aclearwalledchamberwaspressurizedto25mmHgusingaconstantinfusionofwater.Lambbrainwasusedtosimulatethe5cmofcortexthatispassedthroughduringastandardventricularcatheterplacement.High-resolutionphotographswereusedtodocumentthelocationandnumberofpatentholesin20independentcatheterplacements.Animprovedstyletwasengineeredtoreducetheamountofbrainobstructionandwastestedunderthesameconditions.RESULTS: Over87%ofventricularshuntcatheterholes(20.8of24)wereobstructeduponimplantation,althoughtheobstructiondidnotpreventfluiddrainage.Holesclosesttothetipofthecatheterweremostlikelytobeobstructed.Theimprovedstyletprovided2.7xasmanypatentholesasthestandardstylet,8.6comparedto3.2(p-value=0.000004).CONCLUSIONS: Shearingofbrainparenchymaintoventricularcathetersduringinsertionobstructsmostofthedrainageholes.Animprovedstyletreducestissueshearingandprovidessignificantlymorepatentcatheterholes.Additionalpatentholesuponimplantationislikelytoreduceshort-termventricularcatheterfailuresandimprovelong-termperformanceofshuntcathetersbyprovidingmoreunobstructedfluidpathways.
59. ROLE OF ENDOSCOPIC THIRD VENTRICULOSTOMY AND CHOROID PLEXUS COAGULATION IN POST HEMORRHAGIC HYDROCEPHALUS OF PREMATURITYParthasarathiChamiraju,MD;DavidSandberg,MD;JohnRagheb,MD;SanjivBhatia,MD(Miami,FL)INTRODUCTION: Todeterminetheroleofendoscopicthirdventriculostomyandchoroidplexuscoagulation(ETV/CPC)inpatientswithposthemorrhagichydrocephalusofprematurityandtoanalyzefactorswhichaffectpatientoutcomes.METHODS: Weretrospectivelyreviewedmedicalrecordsof27prematureinfantswithintraventricularhemorrhageandhydrocephalustreatedwithETV/CPCbetween2008-2011.AllpatientshadpreoperativeMRIandunderwentendoscopicthirdventriculostomy,septostomyandbilateralchoroidplexuscoagulationwhenfeasible.Thesepatientswerefollowedoveraperiodof6-40months(mean-16.4months).Theprocedurewasconsideredafailureifthepatientsubsequentlyrequiredashunt.Thefollowingfactorswereanalyzedtodetermineapossiblerelationshiptooutcomes:gestationalage,ageandweightatthetimeofsurgery,severityofintraventricularhemorrhageandpriorneedforreservoirplacement.RESULTS: Seventeen(63%)outof27patientsrequiredashuntprocedureafterETV/CPCand10patients(37%)didnotrequiresubsequentCSFdiversion.AfewpatientandradiologicalfactorswereassociatedwithfailedETV/CPC:GradeIVhemorrhage,weightunder3kg,agelessthan3monthsatsurgeryandpreviousreservoirplacement.Themajority(82%)ofETV/CPCfailuresoccurredininitial3monthsandnopatienthadacomplicationdirectlyrelatedtotheprocedure.CONCLUSIONS: ETV/CPCmaybeconsideredasasafeinitialprocedureforhydrocephalusinprematurebabieswithIVHandhydrocephalusinspiteoflowsuccessratetoavoidshuntanditscomplications.Asabovefactorsstudiedmayinfluenceoutcome,webelievethatcarefulselectionofpatientsforthisproceduremightincreasethesuccessrate.
60. THE ASSOCIATION BETWEEN RACE AND MALIGNANT SHUNT FAILURERobertPartlowNaftel,MD;NicoleSafiano,BS;MichaelFalola,MD,MPH;JeffreyBlount,MD;W.Oakes,MD;JohnWellons,MD,MPH(Pittsburgh,PA)INTRODUCTION: Childrenexperiencingfrequentshuntfailure,i.e.,malignantshuntfailure,consumemedicalresourcesandrepresentadisproportionatelevelofmorbidityinhydrocephaluscare.Whilebiologiccausesofmalignantshuntfailuremayexist,thisstudyanalyzeddemographicandsocioeconomicpatientcharacteristicsassociationswithmalignantshuntfailure.METHODS: Asurveyof294caregiversofchildrenwithshuntedhydrocephalusprovideddemographicandsocioeconomiccharacteristics.Childrenexperiencing≥10shuntfailureswereconsideredmalignantshuntfailurepatients.Multivariateregressionmodelswereusedtocontrolforvariables.RESULTS: Malignantshuntfailurewasexperiencedby9.5%(28/294).Byunivariateanalysis,whiterace(p=0.006),etiologyofhydrocephalus(p=0.022),years-with-shunt(p<0.0001),andsurgeon(p=0.02)wereassociatedwithmalignantshuntfailure.Uponmultivariateanalysis,whiteraceremainedthekeyindependentfactorassociatedwithmalignantshuntfailure,OR5.8(95%CI1.2-27.8),p=0.027.Raceactedindependentlyfromsocioeconomicfactors,includingincome,levelofeducation,andgeographiclocation,andclinicalfactorssuchasetiologyofhydrocephalus,surgeon,andyears-with-shunt.Additionally,aftermultivariateanalysissurgeonandyears-with-shuntremainedassociatedwithmalignantshuntfailure(p=0.043andp=0.0098,respectively),althoughetiologyofhydrocephaluswasnolongerassociated(p=0.1).CONCLUSIONS: Whiteracewastheprimaryindependentfactorassociatedwithmalignantshuntfailure.Becauseracesutilizehealthcaredifferentlyandthediagnosisofshuntfailureisoftensubjective,disparityindiagnosisandtreatmenthavearisen.Thesefindingsbeckonobjectivecriteriaforthepreoperativeandintraoperativediagnosisofshuntfailure.
61. VISUAL FINDINGS IN CHILDREN WITH SHUNTED HYDROCEPHALUSJulianJ.Lin,MD;LasunOladeji,BA;AhmadIssawi,MD;LynnLyle,RN(Peoria,IL)INTRODUCTION: Childrenwithshuntedhydrocephalusoftenhaveabnormalvisualfindings.Thisstudyaimstoassessophthalmologicfindingsinchildrenwithshuntedhydrocephalusandspecificallywhetherabnormaleyefindingsleadtoshuntrevisionsurgeries.METHODS: Retrospectivereviewoftheelectronicmedicalrecordsinpediatricpatientsshuntedforhydrocephalusbetween2003-2012.RESULTS: Onehundredtwenty-ninechildreninwhomashuntwasimplantedwereincludedinthisstudy.Therewere73male;meanagewas5.45.Approximatelyonethirdofhydrocephaluswasposthemorrhagic,onethirdduetoneuraltubedefectsandonethirdcongenital.Allchildrenunderwentextensiveophthalmologicexaminationtodeterminevisualacuityaswellasthepresenceofvariousophthalmologicaldisorderssuchasstrabismusandamblyopia.Visualfunctiondeficitswereobservedin74%(95/129)ofchildrenand38%hadmultipledeficits.Ofthedeficitsnoted,strabismus(10),amblyopia(14),disconjugategaze(32),andpapilledema(3)werethemostcommon.Correctivelenseswererecommendedin21%ofthepatientsexamined,while60%ofpatientswithstrabismusrequiredsurgery.Visualfielddeficitsresultedinshuntrevisioninonlyoneinstance,andthatwasduetopapilledema.CONCLUSIONS: Childrenwithshunt-treatedhydrocephalusdisplayahighincidenceofophthalmologicaldysfunction,howeverthisdoesnotappeartobeindicativeoftheneedforshuntrevision.Consideringtheprevalenceofvisualfielddeficitsinthispopulation,itwouldbeprudenttorecommendanophthalmologistconsultforallchildrenwithshuntedhydrocephalus.
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62. ROLE OF PRIMARY CILIA IN DEVELOPING CHICK EMBRYOSTakayukiInagaki,MD;GarySchoenwolf,PhD(SaltLakeCity,UT)INTRODUCTION: Impairmentofciliafunctionunderliesanumberofhumandiseasesincludingneuraltubedefectandhydrocephalus.However,theroleofciliainthedevelopingembryoisnotwellunderstood.Chloralhydrateisknowntohaveanadverseeffectontheciliaformation.Inthispaper,thepossibleroleofciliaindevelopingchickembryoswillbedescribedmainlybyfocusingontheformationofthecentralnervoussystem.METHODS: WhiteLeghornchickeneggswereincubateduntilembryosreachedHamburgerandHamiltonstages4to10.Embryoswerethenremovedfromtheshellandculturedonagarplates.Afterstaging,embryosweretreatedwithachloralhydratesolutionfor20minutes,andreincubated.Embryoswerecollectedfromtheincubatorandexaminedmorphologicallyafterapproximately24hours.RESULTS: Embryostreatedwithchloralhydratedevelopedneuraltubedefects,reversed-sidedheartlooping,andanabnormallyshapedprimitivecerebralventricleinadose-dependentmanner.CONCLUSIONS: Theimportanceofmotileciliainnormalfunctionoftheventricularsystem,includingitsroleincirculationofcerebrospinalfluid,iswidelyrecognized,buttheroleofprimaryciliainearlyembryonicdevelopmentisnotwellunderstood.Inthisstudywefoundthatembryostreatedwithchloralhydratehavereversed-sidedheartlooping,suggestingthatchloralhydratealtersthefunctionofprimarycilia,whichareknowntoplayaroleinestablishingsidedness.Ourresultssuggestthatciliaalsohaveanimportantroleinearlydevelopmentofthecentralnervoussystem,inadditiontoaroleinaxialdevelopment.
63. OMMAYA VENTRICULAR RESERVOIR VERSUS VENTRICULOSUBGALEAL SHUNT FOR POSTHEMORRHAGIC HYDROCEPHALUS: INFECTION RISKS AND VENTRICULOPERITONEAL SHUNT RATESJoannaWang,BA;AnubhavGautamAmin;VivekMehta,MD;BenjaminCarson,MD;GeorgeJallo,MD;EdwardAhn,MD(Baltimore,MD)INTRODUCTION: Posthemorrhagichydrocephalus(PHH)inpreterminfantsoftenresultsinpoordevelopmentalandneurologicaloutcomes.TheOmmayaventricularreservoir(OVR)andtheventriculosubgalealshunt(VSGS),temporarydevicesusedtotreathydrocephalusbeforepermanentinsertionofaventriculoperitoneal(VPshunt),werereviewed.METHODS: Weretrospectivelyanalyzed92patientswithIVHandPPHVDwhoweretreatedwithinsertionofanOVR(n=46)orVSGS(n=46)atourinstitutionfrom1998to2011.RESULTS: ThegestationalageandweightatdeviceinsertionwaslowerforVSGSpatients(mean30.1weeks,1120g)thanforOVRpatients(32.3weeks,1384g;p=0.001,p=0.002,respectively).OVRinsertionwasindependentlypredictiveofmoreCSFtapspriortoVPshuntplacementcomparedtoVSGSplacement(9.7taps,1.6taps,respectively;p<0.001)andOVRpatientshadhigherratesofpositiveCSFculturescomparedtoVSGSpatients(22%,6.5%,respectively;p<0.036).VSGSpatientsexperiencedalongerpostponementofVPshuntplacementthanOVRpatients(80.8days,48.0days,respectively;p=0.002),whichcorrespondedtoVSGSpatientsattainingmoreweightatthetimeofshuntplacementthanOVRpatients(3.3kg,2.5kg,respectively;p<0.01).However,therewerenodifferencesintheratesofovertdeviceinfectionrequiringremoval,VPshuntinsertion,orearlyVPshuntinfectionbetweenthetwocohorts.CONCLUSIONS: VSGSwereinsertedinmoreprematurelybornpatientsandatlowerweightscomparedtoOVR.VSGSrequireslessinvasivemanagementbymanualCSFremoval,lowerratesofpositiveCSFcultures,andallowspatientstoattainhigherweightbeforeVPshuntinsertion.Long-termcognitiveandneurologicalimplicationswarrantfurtherstudy.
64. PERCUTANEOUSLY-PLACED VENTRICULO-ATRIAL SHUNTS VERSUS VENTRICULO-PERITONEAL SHUNTS: BRINGING BACK AN OLD TECHNIQUETylerAmina;RobertKeating,MD;AmeetChitale,MD;JohnMyseros,MD;AmandaYaun,MD;BhupenderYadav,MD;SureshMagge,MD(Washington,DC)INTRODUCTION: Ventriculoperitonealshunts(VPS)havebeenestablishedasthepreferredtreatmentforhydrocephalus.Theadventofpercutanously-placedventriculoatrialshunts(percVAS)hasraisedthequestionoflong-termoutcomesbetweenVPandVAshunts.Therehavebeennorecentstudiescomparingthesetreatmentsinchildren.METHODS: Retrospective,IRB-reviewedstudyof335pediatricpatientstreatedwithanewVPSorpercVASfrom2000-2010.Age,etiology,failurerate(infectious/non-infectious),numberofrevisions,andreasonsforfailurewereanalyzedwithstandardstatisticalmethods.RESULTS: Therewere63newpercVASand300newVPS.Follow-upwas3.96yearsand4.92yearsforVPSandpercVASrespectively.AlmostallpatientsreceivingapercVASpreviouslyhadhadaVPS.InfectionrateforVPSwas8.3%comparedto2%forpercVAS(p<0.005).AcutefailurerateforVPSversuspercVASwas41%and37%respectively(excludingelectivelengthenings)(p=0.56).Kaplan-Meierestimatesdidnotrevealasignificantdifferenceintimetofailure(p<0.2422).However,percVASpatientshadasignificantlybettertimetofailurecomparedtoVPSpatientswithatleastonepriorrevision(p<0.01).CONCLUSIONS: ThesedatashowthatpercVAShadasignificantlylowerinfectionrateandsimilarnon-infectiousacutefailureratecomparedtoVPS.However,percVASpatientshadabettertimetofailurethanVPSpatientswhohadatleastonepriorrevision.Ofnote,almostallpercVASwereplacedinpatientswhowereinherentlymorecomplexandhadfailedpriorVPshunts.PercVASshouldbeconsideredasavaluableoptioninthetreatmentofhydrocephalusandmaybepreferredincertaincomplexpatients.
65. CEREBROSPINAL FLUID LEVELS OF APP AND NCAM-1 CORRELATE WITH VENTRICULAR SIZE IN POST-HEMORRHAGIC VENTRICULAR DILATATIONDavidDelmarLimbrick,MD,PhD;DiegoMorales,MS;RichardHolubkov,PhD;HaejunAhn,BS;DeannaMercer,BS;TerrieInder,MD,PhD(St.Louis,MO)INTRODUCTION: Intraventricularhemorrhage(IVH)isthemostcommon,severecomplicationofpretermbirthandisassociatedwithpost-hemorrhagicventriculardilatation(PHVD)inupto50%ofcases.ThemostdevastatingneurologicaloutcomesareobservedwhenPHVDbecomesprogressiveandrequiresneurosurgicaltreatment.Therelationshipbetweenventriculomegalyandneurodevelopmentaloutcomesremainsunclear.METHODS: Cerebrospinalfluid(CSF)concentrationsofAPP,NCAM-1,andtotalproteinweremeasuredinacohortof12pretermhumaninfantswithprogressivePHVDwhounderwentimplantationofventricularreservoirs.CSFwasremovedasclinicallyindicatedfordecompression.CSFAPPandNCAM-1measurementswerecomparedwithventricularsize(frontal-occipitalratio,orFOR)measuredonheadultrasoundsperformedwithin24hoursofeachCSFsample.RESULTS: CSFlevelsofAPPwerestronglycorrelatedwithFOR.AmodestcorrelationwasobservedbetweenNCAM-1andFOR,butnorelationshipwasfoundbetweentotalproteinandFOR.NormalizingAPPandNCAM-1levelsbytotalproteinstrengthenedtheirassociationwithFOR.Notably,atemporalassociationwasnotedbetweenAPPandFOR,withAPPlevelsparallelingchangesinFORoverthetreatmentinterval.CONCLUSIONS: CSFconcentrationsofAPPandNCAM-1areassociatedwithchangesinventricularsizeininfantswithPHVD.TheseproteinsholdpromiseascandidatebiomarkersofPHH,potentiallyincombinationwithexistingmeasuresofventricularsize.DysregulationofCSFAPPand/orotherproteins,whichmayoccurasaresultofIVHand/oraxonalinjury,mayhaveimplicationsfortheneurologicalimpairmentsobservedinindividualsaffectedbyPHVD.
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66. ERYTHROPOIETIN SIGNALING PROMOTES OLIGODENDROCYTE DEVELOPMENT AFTER PRENATAL HYPOXIC-ISCHEMIC BRAIN INJURYShenandoahRobinson,MD,FAANS;LaurenJantzie,PhD(Boston,MA)INTRODUCTION: Braininjuryfrompretermbirthcauseswhitematterinjury(WMI)associatedwithchronicneurologicaldeficitsincludingcerebralpalsy,epilepsy,andcognitivedelay.Understandinghowthedamageddevelopingbrainrespondstoinjuryisessentialforeffectivetherapydevelopment,andforappropriateselectionofinfantstoreceiveemergingtherapies.Thecytokineerythropoietin(EPO)promotesneuronalrecoveryafterinjurybutitsroleinenhancingoligodendrogliallineagerecoveryafterinjuryduringdevelopmentisunclear.AfterE18TSHIinrats,neonatalexogenousEPOtreatmentenhancesmyelinformationandresultsinsustainedfunctionalrecovery.HereweusedinvitroassaystoinvestigatehowEPOsignalingcontributestooligodendrocyterecoveryintheinjureddevelopingbrain.METHODS: Transientsystemichypoxia-ischemia(TSHI)wasinducedonembryonicday18(E18)inrats.Perinatalmixedcellcultureswereusedtoanalyzestagesofoligodendrocytedevelopmentwithheat-inactivatedEPOandneutralizingEPORantibodiesusedtotestspecificity.Two-wayANOVAwithBonferonni’scorrectionwasusedwithP<0.5significant.RESULTS: EPOsignalingenhancesprocessextensionofimmatureoligodendrocytesinadosedependentmanner(p=0.011).AfterTSHIinjuryonE18,EPOtreatmentpromotesmultipledevelopmentalstepsincludinggenesisofnewoligodendrocyteprogenitorsinoligodendrogliospheres(p=0.044),survivalofoligodendrocyteprecursorcells(OPC)andO4+immatureoligodendrocytes(p<0.01),O4+cellprocessextension(p<0.01)andmyelinformation(p=0.012).EPOdidnotalterOPCproliferation.CONCLUSIONS: WeshowedEPOsignalingcontributestorecoveryofoligodendrogliallineageafterprenatalbraininjury.WMIalsooccurswithothertypesofdevelopingbraininjurysuchashypoxic-ischemicencephalopathyandtrauma,andEPOislikelyeffectiveinthesepopulationstoo.
67. THE MANAGEMENT OF TORTICOLLIS IN INFANTS AND CHILDRENCatherineAnneMazzola,MD,FAANS;LaurenSchwartz,MD;TosanLivingstone,MD;DeborahStraka-DeMarco,PT;TaraGleeson;KaitlynMulhall,RN;StuartWiener,CPO,LPO(Morristown,NJ)INTRODUCTION: Theincidenceoftorticollisandplagiocephalyininfantsishigh.However,thereiswidevariationintheapproachtomanagingthesechildren.METHODS: Aretrospectivereviewof821patientswithplagiocephalyoverasevenyearperiodfrom2005to2012wasdoneutilizingaGECentricityElectronicMedicalRecorddatabase.Therewere475patientswithadiagnosisoftorticollis.Ofthe475withtorticollis,443patientsalsohadplagiocephaly.Infantswithtorticollisandplagiocephalyweremanagedconservativelywithphysicaltherapy,repositioningandcranialmoldingorthoses,iftheparentsdesired.Nopre-treatmentcervicalspinex-rayswereordered,althoughsomeinfantsdidcometotheclinicwithspinalimagingstudiesorderedbyotherspecialists.RESULTS: Allinfantshadimprovementoftheirtorticollisandplagiocephaly,excepteight.Thesechildren,withpersistenttorticollis,despite12monthsofphysicaltherapy,didhavespineimagingstudiesdone.Alleighthadfindingsontheirspineimagingstudies.Twochildrenultimatelyrequiredsurgicalintervention.CONCLUSIONS: Infantswithtorticollisandplagiocephalymaybeconservativelyfollowedwithoutcervicalspinex-rays.Almostallinfantswillbenefitfromphysicaltherapy,repositioningandcranialmoldingorthoses,ifindicated.Cervicalspinex-raysdoneininfants,undertheageofone,areoftennon-diagnostic.Delayingdefinitiveimagingstudiesforneurologicallyintactinfantswithjusttorticollisisfeasible,safeandeffective.
68. SPINAL LEVEL OF MYELOMENINGOCELE LESION IS A CONTRIBUTING FACTOR IN POSTERIOR FOSSA VOLUME, INTRACRANIAL CEREBELLAR VOLUME AND CEREBELLAR ECTOPIA**KieronSweeney;JohnCaird,MD;TaufiqSattar;DavidAllcutt;DarachCrimmins(Donegal,Ireland)INTRODUCTION: McLonesetalstheoryofChiariIIMalformations(C2M)describeshowthelossofCSFviatheopenposteriorneuroporefailstocreateadequatedistendingpressureforthedevelopingrhomboencephalicvesicle.UsingacommonmodelinbiologywedescribedhowthecertainfeaturesofC2Marerelated.METHODS: Weincludedallnew-bornswithspinabifidawhowerebetween4weeksprematureandtwomonths.VolumesandmeasurementswereobtainedfromaxialandsagittalT2weightedMRIimagesofbrainandspine.RESULTS: 56wereidentified.ThereisadirectlinearrelationshipbetweenPFVandCVtothespinalleveloftheMMClesion(p=0.0012andp=0.0041respectively).Thereisanegativelinearrelationshipbetweencerebellardescent,spinalleveloflesionandPFVandCV.Theserelationshipsstrengtheninthosewithnosyringomyelia.Theserelationshipsarenotsignificantinthosewithsyringomyelia.CONCLUSIONS: UsingHagen–Poiseuilleslawtodescribepressureinthefourthventricleasbeingdirectlyrelatedtothelengthofthecentralcanal,fromtheobextotheMMClesion,weareabletoexplainthedirectlyobservedlinearrelationbetweenPFV,intracranialCVandcerebellardescenttothelevelofthespinallesion.Asthismodelassumesauniformradiusofthecentralcanalweareabletovalidatethismodelwhenweobservedastrengtheninginrelationshipsinthenosyringomyeliagroupandstatisticallyinsignificantcorrelationsinthesyringomyeliagroups.ThereforeweproposethatthespinalleveloflesionisoneofthemajordeterminantsofPFV,intracranialCVandcerebellardescent.
69. ENDOSCOPIC THIRD VENTRICULOSTOMY DECREASES VENTRICULO-PERITONEAL SHUNT RATE IN POSTERIOR FOSSA TUMORS**Shih-ShanLang,MD;FabioFrisoli,BS;GregoryHeuer,MD,PhD;PhillipStorm,MD(Philadelphia,PA)INTRODUCTION: Endoscopicthirdventriculostomy(ETV)hasbeenshowntosuccessfullymanagehydrocephalussecondarytotectalregiontumors.However,theeffectivenessofETVforhydrocephalusfromnon-tectalregiontumorsisuncertain.TheaimofthisstudyistodeterminewhetherETVisausefulalternativetoventriculo-peritonealshunts(VPS)forposteriorfossatumorsofvaryinghistologicalsubtypeswhenperformedatthetimeoftumorresection.METHODS: Aretrospectivechartreviewofonepediatricneurosurgeon’spatientspresentingwithhydrocephalusfromanintracranialtumorwasperformed.TherateofsuccessfulETVs(patientswhodidnotrequireaVPS)wasassessedfrom2010-2012(ETVgroup).PatientswhounderwenttumorresectionandVPSinsertionbythesamesurgeonpriortotheintroductionofETVattheinstitutionwereusedascontrols(2005-2010).Subgroupanalysesbasedupontumorlocationandhistologicalsubtypewereevaluated.RESULTS: Twoof20patients(10%)requiredaVPSintheETVgroupcomparedto19of50(38%)inthecontrolgroup(pvalue=0.0177).Patientswithhigh-gradetumorsinnon-tectalandnon-pinealregionshadastatisticallysignificantreductionintheirVPSrate(0/7,0%ETVgroupv.11/26,42%controlgroup,pvalue=0.039).PatientswithaposteriorfossatumoralsoshowedalowerpercentageofshuntratesintheETVgroup.CONCLUSIONS: PerforminganETVatthetimeoftumorresectionforpatientswithhydrocephalusgreatlyreducestheoverallrateofVPSinalltumorlocations,grades,andsubtypes.Patientswithhigh-gradetumorsandposteriorfossatumorsshowedasignificantbenefit.
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70. MULTICENTER IMMATURE LARGE ANIMAL BRAIN INJURY TREATMENT TRIAL: NEUROPROTECTION WITH CYCLOSPORIN AKristenLeighSaliga;SusanMargulies,PhD;ToddKilbaugh,MD;BethCostine,PhD;ColinSmith,MD;CarterDodge,MD;SarahSullivan,MS;ChristopherOwen,MS;SabrinaTaylor,MS;Ann-ChristineDuhaime,MD(Boston,MA)INTRODUCTION: Manyrodentmodelsofneuroprotectiveagentsfortraumaticbraininjury(TBI)havedemonstratedefficacy,butnonehavetranslatedtohumanpatients.Wereportpreliminaryresultsofthefirstmulticenter,immaturelargeanimaldoseescalationtrialofneuroprotectionafterTBI,usingthemitochondrialprotectantcyclosporinAinbothfocalanddiffuseinjurymodelsinpiglets.METHODS: Inthefocalinjurymodelarmofthestudy,onemontholdfemaleYorkshirepiglets(n=55)underwentstandardizedcontrolledcorticalimpact.SubjectswererandomlyassignedtoeithervehicleoroneoffourdosagegroupsofcyclosporinA(n=10/group),andeithera1hour(n=30)or6hour(n=25)delaytotreatmentstarttime.Animalswereeuthanizedviatrans-cardiacperfusion24hoursafterreceivingcontinuousdruginfusionandbrainswereremovedforlesionquantification.RESULTS: Treatmentwith10and60mg/kg/daycyclosporinAdecreasedinjuryvolumecomparedtovehicle-treatedanimalsinthe1hourdelaytotreatmentparadigm,asdidthe10mg/kg/daydoseinthe6hourdelaytotreatmentsubjects.CONCLUSIONS: CyclosporinAappearspromisingforreductionoflesionvolumeintheimmaturepigletbrainafterfocalcorticalinjury.Analysisofothershort-termoutcomemeasuresincludingmitochondrialfunctionandserumbiomarkersinbothfocalanddiffuseinjurymodelsareongoing,andmorelong-termbehavioraloutcomeswillbetestedinthosedosesdeemedpromisingbyinitialphasetesting.ImmaturelargeanimalmodelsmayhelpbridgethegapbetweenrodentmodelsandclinicaltrialsofchildrenwithdifferenttypesofTBI
71. GENE EXPRESSION PATTERNS OF CNS GROWTH AND REGENERATION AT VARIOUS DEVELOPMENTAL STAGES AND AFTER INJURY**EliasB.Rizk,MD;KristaStewart,BS;SivanMeethal,PhD;NithyaHariharan,MD;BermansIskandar,MD(Harrisburg,PA)INTRODUCTION: MolecularmechanismsinvolvedinaxonregenerationofinjuredCNSneuronsmaybesharedwiththedevelopingCNS.Here,westudygeneexpressionofthesepatterns.METHODS: Inaratopticnerve(ON)modelofregeneration,whereaperipheralnervesegmentisgraftedtothecutedgeofan(ON),approximately1%ofretinalganglioncells(RGCs)regeneratethroughthegraft.Usingacelldissociationprotocolfollowedbyflowcytometry,regeneratedRGCneuronswereseparatedfrominjuredneuronsthatdidnotregenerate.RGCsfromratsatvariousembryonicandpostnataldevelopmentalstageswereisolatedinasimilarfashion.RNAextractionandcDNAmircroarrayanalysisallowedacomparisonofgeneexpressionpatternsofthevariousRGC.RESULTS: 196geneswithhigherexpressioninregenerating(R)versusnon-regenerating(I)neuronswereidentifiedbyamodifiedT-test(FDR<0.05).80genesforwhichexpressioninRwaswithin1.5-foldofuninjuredadultneurons(U)and116genesforwhichexpressionwashigherinRversusUwerefurthersubdividedbyhierarchicalclustering.Theaverageofbiologicaltriplicatearraysshowedasubsetofgeneswithhigherexpressioninbothregeneratedaswellasembryonicneurons,withagradualriseinexpressioninthefirst6daysoflife.Heatmapswereplottedtoillustrategeneexpressioncorrelatingtodevelopmentalstages,axonalregeneration,orboth.CONCLUSIONS: Wedifferentiatesignalsassociatedwithaxonregenerationfromthoseassociatedwithinjuryalone.Inaddition,wepresentthefirstexampleofgeneexpressionpatternsthatareexpressedexclusivelyinembryonicneurons,inadultneuronswithpropensitytoregenerateaxonsafterinjury,orboth.Thesefindingshavesignificantclinicalimplications..
72. CSF COMPLICATIONS FOLLOWING INTRADURAL SPINAL SURGERIES IN CHILDRENVictorLiu,BS;PaulSteinbok,MD,FAANS(L);ChrisGillis,MD;DougCochrane,MD;AshSinghal,MD,MSC(Vancouver,Canada)INTRODUCTION: Cerebrospinalfluid(CSF)leakageisacomplicationofintraduralspinalsurgeryandisassociatedwithpoorwoundhealingandinfection.TheincidenceofCSFleakisreportedat16%inadults,butlittleinformationisavailableinchildren.ThepurposeofthisstudywastodeterminetheCSFleakrateandpredisposingfactorsafterintraduralspinalsurgeriesinchildren.METHODS: Thisstudywasaretrospectivechartreviewof589patientswhounderwent638intraduralspinaloperationsatB.C.Children’sHospital(BCCH)toidentifypatientswhodevelopedapost-operativeCSFleakandassociatedriskfactors.CSFleakwasdefinedaspseudomeningoceleorCSFleakthroughincision.Primaryoperationstountetherlipomyelomeningoceles,myelomeningocele/meningoceleclosure,andChiaridecompressionswereexcluded.RESULTS: CSFleaksoccurredin7.0%andwereassociatedwithahigherincidenceofpost-operativewoundinfectionandmeningitis(p=0.0016andp=0.0013respectively).Thetypeofduralsutureused,useoffibringlue,oruseofagraftdidnotaffectCSFleakrates.CSFleaksweremorefrequentwithsimpleversuslockedcontinuousduralsuturing(p=0.0023)andpreviousspinalsurgery(p=0.0001).PatientswithCSFleakwereolderthanthosewithoutleak(98vs72months,p=0.0024).CONCLUSIONS: TheresultsprovideevidenceonintraoperativefactorsthatmaypredisposetoCSFleaksinchildrenwithspinalintraduralsurgeryandmayhelpguidesurgicalpractice.FurtherresearchisneededtoexplainhowspecificfactorsareassociatedwithCSFleaks.
73. EFFECTIVENESS AND LONG TERM CLINICAL OUTCOME OF CONSERVATIVE TREATMENT FOR LUMBAR SPONDYLOLYSIS IN CHILDRENSantoshiShaliniIndrakanti;RoryMurphy,MD;DeannaMercer;JeffreyLeonard,MD;DavidLimbrick,MD,PhD(SantaRosa,CA)INTRODUCTION: Whilelumbarspondylolysisisfrequentlyevaluatedinthepediatricneurosurgeryclinic,littledataexiststoguideclinicalmanagement.Conservativetreatmentiscommonlyemployed,butlongtermclinicaloutcomesusingthisstrategyarepoorlycharacterizedinliterature.METHODS: Retrospectivechartreviewfrom1/1/2000to4/30/2012wasperformedatSt.LouisChildren’sHospitaltoidentifypatientswithsymptomaticbackpainandradiographicevidenceofspondylolysis.PatientswithspondylolisthesisgreaterthangradeIIorconfoundingspinepathologywereexcluded.Follow-upimagingwasreviewedforradiographicchanges(resolution,progression,stability).Wherepossible,telephoneinterviewswereconductedtoassessoutcomesusingSF-8andODIquestionnaires.RESULTS: Outof456patients,36patientswereselectedforparticipationbasedontheinclusion/exclusioncriteriamentionedabove.Radiographicfollow-up,onaveragefor2.1years,wasavailablefor61%ofthepatients.Radiographicresolutionofspondylolysiswasobservedin21.4%whiletheother78.6remainedstable.Phoneinterviewswereconductedanaverageof2.9yearsfollowingsymptomonset.77.8%oftheseparticipantscontinuedaconservativeapproachwhileother22.2%thatwererefractoryunderwentsurgery.TheODI,SF-8PCandSF-8MCscoresfortheconservativeandsurgicalgroupwere15.7%vs.6%,46.5vs.52.75and55.vs.52.4respectively.CONCLUSIONS: Whileamajorityofsymptomaticspondylolysispatientsrespondfavorablytoconservativemanagement,thereremainsasubsetthatfailsthisapproachandeventuallyproceedstosurgery.Ongoingeffortsaredirectedatdevelopingmethodsforearlyidentificationofthissubsettodecreasetheassociatedmorbidity.
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74. OCCIPITAL CONDYLE TO CERVICAL FIXATION IN THE PEDIATRIC POPULATION**LibbyMarieKosnik-Infinger,MDMPH;StevenGlazier,MD;BruceFrankel,MD;AveryBuchholz,MD,MPH(Charleston,SC)INTRODUCTION: Occipitocervicalstabilizationisperformedinchildrenandadultsforvariousconditions.Thepediatricspinepresentsauniquechallengeduetotheimmaturityintheosseousdevelopmentalofachild.Cadavericstudieshaveledtotheuseofoccipitalcondylestoanchorthefixationofanoccipitaltocervicalconstruct.METHODS: Fourpatients,agesthreetoseventeenrequiredstabilizationatthecraniocervicaljunction.Theprimarygoalwastostabilizethespinetopreventfurtherneurologicdeteriorationwhilesimultaneouslyrelievingcompressionatthecraniocervicaljunction.Therearemanyadvantagesofusingoccipitalcondylescrewfixationoveroccipitalbonescrewfixation.Itallowsforamenmagnumdecompression,itcanbeusedifapatienthadapriorposteriorfossasurgery,andlesshardwareispresent.RESULTS: Wedescribefourcasesthatrequiredoperativefixation.Preandpost-operativeimagingandintraoperativedetailsarediscussed.Neuronavigationhashelpedtomakethisasafetechniquetouseinthepediatricspine.CONCLUSIONS: Weshowthatoccipitalcondylefixationcantreatinstabilityinthisregion.Duetotheuniquecharacteristicsofthepediatricspineandcomplexityoftheanatomyinvolved,thistechniqueisanexcellentadjuncttoasurgeon’srepertoireoftreatment.Wewillinvestigatethisconceptfurtherbyreviewingpediatricradiologicstudiestocharacterizetheanatomyatthecraniocervicaljunctionandananalysisofthisdatawillbepresented.Also,asthesechildrencontinuetogrow,wewilllearnhowthisfixationaffectstheirgrowthanddevelopmentatthecraniocervicaljunction.
75. EVALUATION OF HEMORRHAGIC COMPLICATIONS ASSOCIATED WITH PERIOPERATIVE KETOROLAC USE IN PEDIATRIC NEUROSURGERY PATIENTSToddCameronHankinson,MD,MBA;M.Richardson,MD;NicholasPalmeri,BA;SarahWilliams;MichelleTorok,PhD;MichaelHandler,MD(Aurora,CO)INTRODUCTION: Non-steroidalanti-inflammatorydrugs(NSAIDs)arehighlyeffectiveforpostoperativeanalgesia.ManyneurosurgeonsarereluctanttoprescribeNSAIDsintheimmediatepost-operativeperiodduetoaperceivedriskofhemorrhage.Weexaminedthesafetyofaninstitutionalpracticethatincludesthecommonuseofketorolacfollowingpediatricneurosurgicalprocedures.METHODS: Aretrospectiveanalysisof919consecutivepatientstreatedsurgicallybetweenAugust,2006andJune,2012.Dataincludeddemographics,typeofsurgery,ketorolacuse,potentialmedicalconfounders(ie.anticoagulantorantiplatelettherapy),andcomplications(ie.radiographichemorrhage,clinicallyrelevantbleedingevents,renalfailure,orgastriculcer).Clinicallyrelevantbleedingeventsweredefinedasthosethatrequiredreoperation.Radiographichemorrhagewasassessedonaxialimagingwithin7daysofsurgeryandbasedonthefinalradiologyreport.Chi-squareanalysisandmultivariablelogisticregressionusingthebackwardselectionapproachwereperformed.RESULTS: Clinicallysignificantbleedingeventsoccurredin9of919(0.98%)patients.Axialimagingwithin7daysofsurgerywascompletedin371(40.4%).Ofthese,31(8.4%)demonstratedhemorrhage.Afteradjustingforage,gender,medicalconfounders,andsurgeon,statisticalanalysisdemonstratednosignificantassociationbetweenclinicalbleedingevents(OR=4.3,95%CI0.5-37.2)orbleedingdetectedonpost-operativeimaging(OR=1.4,95%CI(0.6-3.2))andpatientsreceivingketorolaccomparedtothosewhodidnotreceiveketorolac.CONCLUSIONS: Althoughtheinfrequencyofbleedingeventslimitsstatisticalpower,ketorolacdoesnotappeartobeassociatedwithastatisticallysignificantincreaseinriskofclinicallysignificantbleedingeventsorradiographichemorrhageinpediatricneurosurgicalpatients.
76. DEFINING REASONABLE MEDICAL CERTAINTY IN CHILD ABUSE COURT CASESMarkS.Dias,MD,FAANS;BenjaminLevi,MD;WilliamWenner,MD;MarkIantosca,MD;SusanBoehmer,MS(Hershey,PA)INTRODUCTION: Neurosurgeonstestifyinginchildabusecasesareroutinelyaskediftheiropinionsareexpressedwithinreasonablemedicalcertainty(RMC).However,thedefinitionofRMCisnotwelldefinedlegallyandexpertwitnessesmayusewidelydifferentthresholdsforRMCwhentestifying.Wehypothesizedthattherewouldbesignificantvariabilityamongmedicalexperts.METHODS: Wesurveyedphysicians,includingpediatricneurosurgeons,whotestifyasexpertwitnessesinchildabusecourtcases,toestablishtheirdefinitionsofRMCandthefactor(s)thatledtotheirdefinition.RespondentswereaskedtodefineRMCbothinnumerical(percentageprobability),ordinal(first,second,etc.mostlikelydiagnosis)andlegal(reasonablemedicalcertainty,preponderanceoftheevidence,beyondareasonabledoubt)terms.RESULTS: Wereceived294responses.ThedefinitionofRMCthatabusehadoccurredvariedwidely,rangingfrom≥25%to≥99%;overthreequartersofrespondentsuseda≥90%threshold.NearlyhalfidentifiedRMCmostcloselywitha‘clearandconvincing’standard,withone-fourtheachidentifyingRMCmorewith‘preponderanceoftheevidence’or‘beyondareasonabledoubt’standards.Therewerenocorrelationswithanydemographicvariableexceptthedefinitionrespondentshadreceivedduringtraining.CONCLUSIONS: Thereissignificantvariabilityinmedicalexpertwitnesses’definitionsofRMC.Theimplicationsofthisaresignificantandcreatearealpotentialforinjustice.Wecalluponthelegalandmedicalprofessionstoeitherabandonthetermaltogetherorcometogethertoprovideaconsistentanduniversaldefinitionoftheterm.
77. USE OF MRI-STIR IMAGING IN PEDIATRIC TRAUMATIC CERVICAL SPINE CLEARANCEStevenHwang,MD;MarkHenry;KatherineScarlata;AmyKalleen,BS;AlexisChavez,BS;RonRiesenburger,MD;JamesKryzanski,MD;LeslieRideout,RN;AmerSamdani,MD;(Boston,MA)INTRODUCTION: AlthoughMRI-STIRimaginghasbeenvalidatedintheclearanceofadultcervicalspinetrauma,itsbenefitinpediatrictraumaremainsunclear.Wesoughttoanalyzeourinstitution’spracticepatterns,assessingtheuseofSTIRimagingtoclearthecervicalspineinpediatrictrauma.METHODS: Weretrospectivelyanalyzedtraumapatientsundertheageof18atTuftsMedicalCenter,aLevel1pediatrictraumacenter(2002-2011),whoreceivedcervicalspineMRIsinanattempttoclearthecervicalspine.RESULTS: 134patients(meanage=10±5.5yrs)wereidentified,ofwhich110wereclearedasanin-patient.Ofthese,108hadnegativeMRIs.2hadpositiveMRIsbutwereclearedusingflexion/extensionradiographs.OfthosewithnegativeMRIs,101wereclearedsolelybyMRI;7receivedfurtherstudiesduetophysicianpreference.Ofthese7patients,5wereclearedwithflexion/extensionfilms,1wasclearedwithaCTscan/clinicalexam,and1wasclearedclinically.74of110patientsclearedbynegativeMRIhadnoreportedsymptomsonfollowupappointment(meanfollowup9±18months).36didnothaveafollowupappointmentonrecord.SpecificityforMRI-STIRimagingforcervicalspineclearancewas97%.CONCLUSIONS: MRI-STIRimagingmayplayasignificantroleintheclearanceofthepediatriccervicalspineintraumaasastand-aloneclearancetool.However,prospectivestudiesareneededtoevaluateandvalidatetheimpactofitsusageongeneralpatientoutcomes.
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78. THE IMPORTANCE OF A RADIOGRAPHIC FATTY FILUM IN THE DIAGNOSIS OF TETHERED CORD SYNDROME**EricMichaelThompson,MD;MichaelStrong,BS;GarthWarren,MD;NathanSelden,MD,PhD(Portland,OR)INTRODUCTION: ThepurposeofthisstudywastocorrelatehistologicandMRIcharacteristicsofthefilumterminaleinpatientswithtetheredcordsyndrome(TCS).METHODS: HistologicfilumspecimensandMRIsofpatientswhounderwentfilumtransectionwerereviewed.MRIvariablesassessedincludedconuslevelandpresenceofafattyorthickened(<2mm)filum.Histologicalvariablesincludedpresenceofnervetwigs,andfibrous,vascular,adipose,andglial/ependymaltissue.RESULTS: From2000to2011,298patientshadcompleteMRIandhistologicdataandwereincludedinthestudy.Themeanagewas7.0years(range0.1to64.3).Fibroustissuewasfoundin94.8%,nervetwigsin78.5%,adiposetissuein58.8%,vasculartissuein36%,andglial/ependymaltissuein19.5%ofspecimens.Histologicfeaturesassociatedwitharadiographicthickenedfilumwereadiposetissue(OR3.6,95%CI2-6.4,P<0.001),nervetwigs(OR2.2,95%CI1.1-4.5,P=0.036),andvasculartissue(OR0.5,95%CI0.3-0.9,P=0.025).Onlyadiposetissue(OR2.2,95%CI2.4-0.9,P=0.028)wasassociatedwithaconuslevelbelowtheL2-3discspaceandwitharadiographicfattyfilum(OR10,95%CI5.2-19.1,P<0.001).CONCLUSIONS: FibroustissuewasfoundinnearlyallspecimensandlikelyplaysakeyroleinthepathophysiologyofTCS.Additionally,adiposetissuewassignificantlyassociatedwithlowerlyingpositionoftheconusandathickenedfilum.Hence,itmaybethemostimportantradiographicfeatureinthediagnosisofTCS.
79. CHIARI I MALFORMATION AND SPORTS: EVALUATING THE RISK OF INJURY**JenniferMaeStrahle,MD;ReginaBower,MD;BelaSelzer,NP;HughGarton,MD;KarinMuraszko,MD;NicholasWetjen,MD;CormacMaher,MD(AnnArbor,MI)INTRODUCTION: ChiariImalformation(CM)maynarrowCSFspacesintheuppercervicalcanal.ItisunclearifthereisanincreasedriskofspinalcordinjurywithCMinsports.METHODS: SurveysonsportparticipationwereadministeredtoconsecutivepatientswithCMseeninpediatricneurosurgeryclinicattheUniversityofMichiganortheMayoClinicbetweenDecember2010andJuly2012.RESULTS: 146patientswereincludedinthestudy.MeanageatCMdiagnosiswas8years(0.5-18),meanageattimeofsurveywas14years(1-32)and53%werefemale.Averagetonsillarherniationwas8mm(5-30),54hadpeggedtonsils,35patientshadasyrinxand9hadadilatedcentralcanalorpre-syrinx.53(36%)patientshadahistoryofsurgery.61%(89)ofpatientsparticipatedin28differentsports,with54participatingincontactsports.Patientsplayedbetween1and6sports.Themostfrequentlyplayedsportsincludedsoccer(n=29),basketball(n=23),andvolleyball(n=15).Thegroupasawholeparticipatedinatotalof659yearsofsportswithanaverageof7.6yearsperperson,and5months/yearpersport.Therewasonecaseoftransientnumbnessandweaknessafterfallingwhileplayingsoccerwithoutradiographicevidenceofinjury.Therewerenopermanentinjuries.CONCLUSIONS: Participationincontactandnon-contactsportsdoesnotseemtoplacepatientswithCMatincreasedriskofinjury.Continuedprospectivestudyisneeded.
80. CHIARI I MALFORMATIONS: INSTITUTIONAL EXPERIENCE OF 158 PATIENTS REVIEWING SYMPTOM RESOLUTION BASED ON OPERATIVE INTERVENTIONReneeM.Reynolds,MD;KeikoWeir;DavidBauer,MD;SamuelBrowd,MD,PhD;RichardEllenbogen,MD(Seattle,WA)INTRODUCTION: ChiariImalformations(CM1)interferewithnormalCSFcirculationleadingtovarioussymptoms.Consensusregardingmethodsofsurgicalinterventionislacking.Thisstudywasaimedatdeterminingdifferencesbetweenoperativetechnique,symptomresolutionandcomplications.METHODS: PatientsundergoingsurgeryforCM1atSeattleChildren’sHospitalbetween1997-2009wereretrospectivelyreviewed.Bonydecompressionswithorwithoutduraplastywereperformedatthediscretionofthesurgeon.Adatabasewasestablishedreviewingsurgicalintervention,pre-andpost-operativesymptoms,timetoresolution,andcomplications.RESULTS: Onehundredandfiftyeightpatientswereidentified.Agesrangedfrom1.14-20.19(mean9.94±4.81)withafemale:maleratioof1.1:1.Forty-threeposteriorfossabonydecompressionsandonehundredandtwentytwoadditionalduraplastieswereperformed.Symptomswiththehighestpercentageofpostoperativeresolutionwereoccipitalheadaches(94.5%),neckpain(89.5%),andfrontalheadaches(88.3%).Exceptforsyringomyelia,therewerenostatisticallysignificantdifferencesinsymptomresolutionratesortimetoresolutionbysurgicaltechnique.Sixtythreepercentofpatientswithsyringomyeliahadcompleteresolutionalthoughpatientswhounderwentduraplastyweremorelikelytohaveresolution.(68%vs20%,p=.0224).Commoncomplicationswerenewheadaches(8.75%)anddysesthesias(3.75%)withnostatisticallysignificantdifferencebyoperativeintervention.Complicationsexclusivetoduraplastyincludedasepticmeningitis(4.17%),pseudomeningocele(4.17%)andCSFleak(1.85%).CONCLUSIONS: WerecommendbonydecompressionforpatientswithCM1intheabsenceofsyringomyeliaandadequatetonsillarpulsatilityonintraoperativeultrasound.Allpatientswithsyringomyeliashouldundergobonydecompressionwithduraplasty.
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81. THE CASE FOR INTERNATIONAL PEDIATRIC NEUROSURGICAL EXPERIENCES: A BREAKDOWN OF US RESIDENT EXPERIENCES WITH PEDIATRIC SPINAL DYSRAPHISM CASESBrandonG.Rocque,MD;HumphreyOkechi,MD;KimberlyFoster,MD;LukeTomycz,MD;JonathanForbes,MD;LelandAlbright,MD;SandiLam,MD(Madison,WI)INTRODUCTION: IntheNationalResidentReportofNeurologicalSurgeryCaseLogspreparedbythedepartmentofApplicationsandDataAnalysisoftheACGME,theResidentReviewCommitteeforNeurologicalSurgeryconductedasurveyofthetotalexperienceofresidentscompletingprogramsin2009-2010.METHODS: ReviewofcasenumbersfromtheRRCsurveyandatanEastAfricanhospitalwithvisitingUSneurosurgicaltraineeswasconducted.RESULTS: USresidentsreportedtheirexperienceswiththeACGMEindexcasescategorizedas“dysraphism–pediatriccases.Thecaseexperiencetotalsacrossallyearsofresidencyarereportedaspercentiles:20thpercentile:2cases,50thpercentile:7cases,90thpercentile:16cases.Thenationalresidentaverageofpediatricspinaldysraphismcasestotaledforallyearswas7.9cases.Incontrast,8spinaldysraphismcaseswerereportedperresidentoveranaverage2-weekrotationatKijabeHospitalinKenya.ThepediatricneurosurgeoninresidenceatKijabehasloggedover300spinaldysraphismcasesperyearsincesummerof2010.A4-weekinternationalresidentrotationcouldpotentiallyprovideexperiencewithanaverageof4myelomeningocelecasesperweek.Overonemonth,thiscouldeclipsethe90thpercentileofUSresidentexperienceforanentireresidency.ThisisborneoutbyindividualexperiencesofresidentswhohavevisitedDr.LelandAlbrightinKijabe,Kenyaoverthepastyear.CONCLUSIONS: Theroleandvalueofinternationalneurosurgicalexperiencesforresidencytrainingcanbesignificant,especiallyfortreatmentofpathologiesrarelyencounteredintheUS.
82. ISOLATION OF NEURAL STEM CELLS FROM MYELOMENINGOCELE PLACODES WITH POTENT OLIGODENDROCYTE FORMING ABILITYSamuelH.Cheshier,MDPhD;ShararehGholamin,MD;SiddharthaMitra,PhD;ChaseRichard,BS;MichaelEdwards,MD(Stanford,CA)INTRODUCTION: Myelomeningoceleisacongenitalanomalyofspinalcordresultingfromadefectintheclosureoftheneuraltubeduringtheforthweekofembryonicdevelopment.Duetothisearlygestationaldefectintheclosureofcaudalneuropore,wehypothesizedthattissuesampleobtainedcouldproverichforneuralstemcellsandgiverisetoallthreelineagesofneuralcells–neurons,astrocytesandoligodendrocytes.METHODS: ThreeneuralplacodesampleswereobtainedfromtheLucillePackardChildren’sHospital(Stanford,CA).Thetissuesweredissociatedintoasinglecellsuspensionandplatedinenrichedneurobasalmediawithgrowthfactors.Followingneurosphereformation,cellswereplatedinpoly-D-ornithineandlaminincoated8chamberpolystyrenetissuecultureslides,wheretheywereallowedtogrowundersixvariousdifferentiationconditionsfortwoweekspriortostainingwithappropriatesurfacemarkers.RESULTS: ThedifferentiatedcellsstainedhighlypositiveforoligodendrocytemarkersCNPaseandO4andmoderatelypositiveforastrocytemarkerS100b,andneuronalmarkersTuj1,MAP2andTBr-2.FaintGFAPstainingwasnoted.WefoundSox2andNestinstainingincellsgrowninsphereformingmedia.CONCLUSIONS: Greatinterestexistsinthepotentialutilityofneuralstemcellsandprogenitorcellsassubstratesforstructuralrepairofthecentralnervoussystem.Ourfindingssuggestthatneuralplacodetissuemayserveasauniquesourceofmultipotentstemcellswithpotentoligodendrocyteformingabilityandcouldproveusefulinfurthertranslationalstudies.
83. THE DISTRIBUTION OF CEREBELLAR TONSIL HEIGHT DEFINED BY AGE: IMPLICATIONS FOR UNDERSTANDING CHIARI MALFORMATIONCormacO.Maher,MD,FAANS;JenniferStrahle,MD;HughGarton,MD;KarinMuraszko,MD;BrandonSmith,BS(AnnArbor,MI)INTRODUCTION: Priorattemptstodefinenormalcerebellartonsillarpositionhavebeenlimitedbysmallnumbersofsubjectsthathaveprecludedanalysisofnormaldistributionbyagegroup.Ourobjectiveistoanalyzecerebellartonsillarpositionineveryagegroup.METHODS: 2400subjectswererandomlyselectedandorganizedinto8agegroupsfromadatabaseof62,533consecutivesubjectsundergoingimaging.MRIsweredirectlyexaminedfortonsillocation,morphologyandotherfeatures.ThosewithahistoryorimagingfindingofposteriorfossaabnormalitiesnotrelatedtoCMwereexcluded.Measurementsofcaudalextentofthecerebellartonsilsweremadeatmid-sagittalandthelowestparasagittalposition.RESULTS: Themeantonsillarheightdecreasedslightlywithadvancingageinchildhoodandincreasedwithadvancingageintheadultagerange.Increasingageintheadultagerangewasassociatedwithadecreasedlikelihoodoftonsilposition5mmormorebelowtheforamenmagnum(p=0.0004).Ingeneral,thedistributionoflowesttonsilpositionineachagegroupfollowedanormaldistribution.Patientswithpeggedmorphologyweremorelikelytohavetonsillarlocationatleast5mmbelowtheforamenmagnum(85%),comparedwiththosewithintermediate(38%)androunded(1.7%)morphology(p<0.0001).Femalesexwasassociatedwithlowermeantonsilposition(p<0.0001).Anincreasingtendencyforasymmetrictonsilposition,especiallywithalowerrighttonsil,wasnotedwithlowertonsilposition(p<0.0001).CONCLUSIONS: Cerebellartonsilpositionfollowsanessentiallynormaldistributionandvariessignificantlybyage.ThisfindinghasimplicationsforadvancingourunderstandingofCM.
84. LONG TERM FOLLOW UP IN TETHERED SPINAL CORD FOLLOWING MYELOMENINGOCELE CLOSUREJeffreyP.Blount,MD;ChristiBoddiford,BA;BetsyHopson,BA;ChevisShannon,PhD(Birmingham,AL)INTRODUCTION: Limitedlongtermfollowupdataisavailableaddressingoutcomesofsurgicaluntetheringoftetheredspinalcord(TSC)thatoccursatpriormyelomeningocele(MMC)closure.Wereviewedasingleinstitutionexperienceoveradecadetostudyourexperiencewiththisissue.METHODS: WeidentifiedacohortofMMCpatients(n=36)whounderwentsurgicaluntetheringbetween2000and2010atthesiteofpriorMMCclosure.Neurologic,orthopedicandurologicoutcomespostuntetheringweretabulated.Thirtyseventosixtymonthfollowupwasavailableon24patients.RESULTS: Thirtysixpatientsunderwent43untetheringprocedures.AverageageofpresentationwithTSCdidnotdiffersignificantlybyMMCsite(thoracic6.4+-3.1yrs,lumbar7.0+/-3.0yrs,sacral8.6+/-4.7yrs).ThemostcommonsignsofTSCwerelowerextremityweaknessorgaitchange(n=13),scoliosis(n=11),backpain(n=6)andcontinencechanges(n=5).Acute(<3months)post-operativeproblemsoccurred12timesincluding5VPshuntfailures,3episodesofincreasedweaknessand2woundissues.Acuteneurologicoutcomesshowedarrestofdeclinein4patients,improvementin6patientsandnoneurologicchangein16patients.Twopatientsshowedimagingimprovementswithnoclinicalchange.Longtermresultsshowedclinicalstabilityorcontinuedimprovementin26patients.CONCLUSIONS: UntetheringofTSCatpriorMMCsiteiseffectiveatarrestingneurologicdecline.Longtermstabilityofacuteresultsisrealizedinthemajorityofpatients.VPshuntfailurefrequentlycomplicatesuntetheringprocedures.
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101. A NOVEL CRANIAL REDUCTION TECHNIQUE TO FACILITATE THE MANAGEMENT OF NEONATAL MACROCEPHALY RELATED TO HYDROCEPHALUSGeraldTuite,MD;JothamCharlesManwaring,MD;ArmenDeukmedjian,MD;DevonTruong;CarolynCarey,MD;LuisRodriguez,MD;BruceStorrs,MD;LisaTetreault;(Tampa,FL)INTRODUCTION: Themanagementofnewbornswithextrememacrocephalyrelatedtohydrocephaluscanbedifficult.Excessivecerebrospinalfluiddrainagecanresultinsignificantsutureoverlap,whichleadstodifficultiesinpatientpositioning,secondarysynostosis,andlong-termaestheticcomplications.Delayedcranialreductionandremodelingprocedurescarrysignificantriskandtheaestheticoutcomeshavesometimesbeenpoor.METHODS: Wedescribethetechnicalstepsinanovelcranialreduction/fixationprocedurethroughpictureandvideo.Thecasesoftwoneonateswithseveremacrocephalyrelatedtohydrocephalusarepresented.Cranialreductionandfixationwasperformedwithalargeabsorbableplateduringthefirstweekoflife.RESULTS: A49%intracranialvolumereductionandanimmediate,markedimprovementinappearancewereattainedinbothpatients.Clinicalandaestheticoutcomewasexcellentatoneyearinthefirstpatient.Four-monthfollow-upwillbepresentedforthesecondpatient.CONCLUSIONS: Thisnovelmanagementstrategyfacilitatedpatientpositioning,simplifiedhydrocephalusmanagement,andprovidedanexcellentaestheticoutcome.Specialemphasisisplacedonperioperativehydrocephalusmanagementandoperativetechniquesinthesetwocases.Abriefhistoryofcranialreductionsurgeryisalsopresented.
102. ACQUIRED CHIARI MALFORMATION FROM CYSTOPERITONEAL SHUNTING IN THE PEDIATRIC POPULATIONNeenaIshwariMarupudi,MD;JohnMathieson,BS;KeshavGrover,BA;StevenHam,DO;SandeepSood,MD(Detroit,MI)INTRODUCTION: Occurrenceofacquiredtonsillarherniationsecondarytocystoperitoneal(CP)shuntingisrarelydocumented,althoughitmaybeacommonandseriousconcerninpatientsshuntedatayoungerage.METHODS: Weperformedaretrospectiveanalysisof37pediatricpatientswitharachnoidcysts(ACs)whounderwentinsertionofaCPshuntandidentifiedfourpatientswhosubsequentlydevelopedaChiariImalformation(CM).WereviewedCT/MRIstudiesforosseous/dimensionalchangesofthecranialvault.Wealsoinvestigatedclinicalmanifestations,ACandshuntcharacteristics,andoutcomes.RESULTS: 60%ofpatientsunderwentCPshuntinsertionatlessthan3yearsofage,primarilyforsupratentorialACs.Fourpatients,allshuntedbeforeagethree,developedaCM;theacquiredCMwasdemonstratedbetween2-5yearsaftershuntinsertiononfollow-upimaging.Threeof4patientsrequiredrevisionsforshuntmalfunctionwithinoneyearofinsertion,withtwopatientsexperiencingover-drainagesymptoms.ObservationalanalysesofimaginginpatientswithacquiredCMsandthoseshuntedbeforeage3suggestposteriorfossa(PF)overcrowdingduetolackofage-appropriatecranialvaultgrowth;PF-space-volumeaveragedabout18%lessthanage-matchedcontrols.TheprevalenceofacquiredCMinourpatientpopulationofshuntedACsisabout11%,andabout20%ofthoseshuntedbeforeage3.CONCLUSIONS: OsseouschangesinthePFandacquiredCMcandevelopinpatientswithshuntedACs,particularlywhenshuntsareplacedbeforetheageof3.TheresultingCSFhypotensionatayoungage,combinedwithvenousdistension,stuntsosseousgrowthinthePF.
103. AN ALTERNATIVE HYPOTHESIS FOR ARACHNOID CYST FORMATIONPaulA.Grabb,MD(ColoradoSprings,CO)INTRODUCTION: Arachnoidcystsareconsideredtobelesionsofdevelopmentaletiology.Thetraditionalpathogenesishasbeenconsideredapoorlydefinedsplittingofthearachnoidduringdevelopment,andaball-valvemechanismofCSFaccumulation.Wepresentacasethatproposesanalternativeoradditionaletiologytocongenitalcystformation.METHODS: A13month-oldwithalargemiddlefossacystpresentedwithimagingandclinicalcharacteristicsofatypicalarachnoidcyst.Theclinicalcourseandcystevolutioninthischildaredocumentedbyfetalandpostnatalmagneticresonanceimaging(MR)andcomputerizedtomography(CT).RESULTS: This13montholdboypresentedwithtemporalbonebulgingandnoothercomplaints.Hewascruising.HismotherhadafetalMRforabnormalfetalmotion.ThefetalMRdisplayedahemorrhagiclesionintherighttemporallobe.Postnatalimagingdisplayedencephalomalaciaandhemosiderinthroughthefirstsixmonthspostnatally.Otherthanthetemporalbulgeandmildesotropiahisexaminationwasnormal.ACTscandisplayedfindingsconsistentwithalargemiddlefossaarachnoidcyst.Heunderwentendoscopicfenestrationofthecystintothebasilarcisterns.Theintraoperativefindingsweretypicalformiddlefossaarachnoidcysts.CONCLUSIONS: Thiscasedocumentsaprimaryintraparenchymalhemorrhagiceventoccurringprenatally,thatoneyearlaterresultedinaclinicalpresentationconsistentwithatypicalcongenitalarachnoidcyst.Whilethehistoricalpresumedpathogenesisofarachnoidcystsmaybetrueinsomeormostcases,othermechanismssuchasperinatalhemorrhagemayplayaroleinthepathogenesisofcongenitalcysts.
104. ANGIOCENTRIC GLIOMA, A CASE REPORT AND A LITERATURE REVIEWDanielaAlexandru,MD;BijanHaghighi,MD;MichaelMuhonen,MD(Orange,CA)INTRODUCTION: Angiocentricgloma,pediatricbraintumor,hasbeenrecognizedonlysince2007WHOClassificationofTumorsoftheCNS.METHODS: Atwelveyearoldchildpresentedwithintractableseizuresandalesioninthetemporallobe,hyperintenseonT2andFLAIRmagneticresonanceimagesandnotenhancingwithcontrast.Grosstotalresectionwasperformedandthepatienthadcompleteseizurecontrol.Histologicalythelesionwascomposedofmonomorphouscellsarrangedinaperivascularpattern,withvariableimmunoreactivitytoGFAP.Toestablishprognosisandtreatment,aliteraturereviewwasperformedand28patientswithangiocentricgliomawereidentified.RESULTS: Ofthese,96%presentedwithintractableseizuresandonlythreepatientshaddifferentsymptoms,onehaddecreasedvisionandheadaches,anotherhadotalgiaandthethirdwasataxic.In27patientsthetumorswereinsupratentoriallocation.Theageatsurgeryrangedfrom2to14years,suggestingthatthisisaprimarilypediatricbraintumor.Sixteenofthetwentyninepatientsunderwentgrosstotalresectionwithcompleteseizurecontrol.Oftheninepatientswhohadsubtotalresection,fourhadseizurerecurrence.Thebrainstemangiocentricgliomapatienthadbiopsy,followedbyradiationtherapy.Attwoyearfollowupthepatientwasseizurefree,andthetumorhasnotincreasedinsize.CONCLUSIONS: Angiocentricgliomapresentsmostoftenwithseizures,grosstotalresectioniscurativeandnoradiationorchemotherapyisneededincaseswheregrosstotalresectionwasachieved.Forunresectabletumors,theadditionofradiationtherapyhelpscontrolseizuresandtumorprogression.
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105. APLASIA CUTIS CONGENITA AND TRIGONOCEPHALY: A VARIATION OF CRANIOECTODERMAL DYSPLASIAAlexandreCasagrandeCanheu,MD;LuizGustavodeSouza,MS;SergioGeorgeto,MD;MarcosDias,MD;FahdHaddad,MD(Cianorte,Brazil)INTRODUCTION: Cranioectodermaldysplasia,asknownasSensenbrennersyndrome,isarareandheterogeneousconditionhardtodealwithinourdailypractice.Thiscasepresentsaconservativeneurosurgicalapproachofthisdisease.CaseReport:A15monthsgirlwithapasthistoryofprematuredeliveryharboringaplasiacutiscongenitalalreadyhealed,chronicanemia,gastroesophagealreflux,craniosynostosisnamedastrigonocephaly,generalizedseizures,motordelay,congenitalheartdiseasenamedasinteratrialcommunication,thinhair,lowweightandheight.Shehasanunclewhowasbornwithaplasiacutiscongenitalaswell.METHODS: Patienthasbeenfollowedupfor2yearsasaconservativeneurosurgicalapproachwhereasshewassubmittedtoacardiacoperationandhasbeendoingwellsinceit,recoveringpartiallytheweightandheight.Thechronicanemiadidnotrecoverenough.Theparentswerenotconfidenttoacceptneurosurgicalrepairconsideringtheaestheticalappearancewassatisfactory.RESULTS: Thegirlhasbeenconsultedeverythreemonthspresentingaslightfrontalkeenwithslowalbeitprogressiveneurologicalimprovement.Nowadayssheisthreeandahalfyear-oldandshecanstandandwalkwithalittlehelp,althoughwithpoorlanguagestatus.Theseizureshavebeenceasedwithpropertreatment.Westillholdthewaitandseedecisiononcetheparentsaresatisfiedwithherface.CONCLUSIONS: Thereareamyriadofpatternsencasingthecranioectodermaldysplasia,andwemustanalyzeeachcaseseparatelyknowingthatinmanycasesthelesserwedoisthebettertodo.
106. ARACHNOID CYSTS AND UNDIAGNOSED IDIOPATHIC INTRACRANIAL HYPERTENSIONRachanaTyagi,MD;KevinAnton,BS;JanWollack,MD(NewBrunswick,NJ)INTRODUCTION: Idiopathicintracranialhypertension(IIH)isaconditioncausedbychronicelevationofintracranialpressureintheabsenceofintracranialmass,obstructivehydrocephalus,orotherknownetiologyproducingneurologicalsequelaesuchasheadache,nausea,vomiting,andpapilledema.Similarsymptomsrelatedtoincreasedintracranialpressureareseeninthepresenceofarachnoidcysts.METHODS: Wereport2pediatricpatientswithIIHwhopresentedwitharachnoidcysts.RESULTS: Bothpatientsweresurgicallytreatedwithcystfenestrationwithrecurrentdevelopmentofpseudomeningocelespost-operatively.Bothwereeventuallydiagnosedwithidiopathicintracranialhypertensionandsuccessfullytreatedmedically.CONCLUSIONS: ThesecasessuggestanassociationbetweenarachnoidcystsandIIH,whichmaybeusefulinprovidingamoretimelydiagnosis,providingappropriatetreatmentandavoidingunnecessarysurgery.
107. ARNOLD CHIARI TYPE 1 MALFORMATION PRESENTING WITH SLEEP DISORDERED BREATHING IN WELL CHILDRENEliasB.Rizk,MD;ShaneTubbs,PhD;JerryOakes,MD;CurtisRozzelle,MD;JamesJohnston,MD;JeffreyBlount,MD;JohnWellons,MD,MSC(Harrisburg,PA)INTRODUCTION: TheChiaritype1malformationisacongenitalbrainstemabnormalitycharacterizedbycaudalherniationofthecerebellartonsilsthroughtheforamenmagnumresultingincrowdingatthecranio-cervicaljunction.METHODS: 3patientspresentedwithseverecentralapneaandseverecompressionoftheforamensegmentwithmagneticresonanceimagingconfirmingthediagnosisofChiari1.RESULTS: 3patientsunderwenturgentsurgicaltreatmentwithaposteriorfossadecompressionformarkedcentralsleepapneaattheChildren’sHospitalofAlabamabetween1993-2012.Achartreviewwasperformedtodeterminethenaturalhistoryofthecentralsleepapneaandthetimetoreversalofsymptomsfollowingsurgicaldecompression.CONCLUSIONS: Basedonourexperience,urgentsurgicaldecompressionisrecommendedincasesofChiaritype1malformationwithsignificantbrainstemcompressionandcentralsleepapneawithnootheretiology.
108. ASYMPTOMATIC SYRINGOMYELIA WITH SCOLIOSIS IN A SIBLING GROUP WITHOUT CHIARI I MALFORMATIONSCatherineMazzola,MD;BenjaminHorowitz;MarkRieger,MD(Teaneck,NJ)INTRODUCTION: Theclinicalmanagementofchildrenwithasymptomaticsyringomyeliaischallenging.ScoliosisandChiariImalformationarepresentinmanychildrenwithsyringomyelia,andtheseco-morbiditiesarefrequentlyfoundinasymptomaticpatients.ThediagnosesofsyringomyeliaandscoliosisinasiblinggroupwithoutChiariImalformationshaverarelybeenreported.Herewepresentanunusualcasereportoftwosiblingswhowerediagnosedwithdextro-scoliosisandsyringomyelia,withoutChiariImalformationsandwithoutsignificantneurologicaldeficits.METHODS: Eachpatientunderwentserialspinalmagneticresonanceimaging(MRI)scanswhichrevealedsimilarsyrinxes,4-7mmindiameter,betweenT-5andT-12.Bothsiblingsbeganwearinganight-timeProvidencebraceaftertherightthoraciccurveprogressedtoapproximately26degrees.Patientswerefolowedneurologicallyandorthpedically.RESULTS: SinceapplicationoftheProvidencespinalorthosis,theircurveshavereducedtoabout15degreeswhenmeasuredwithoutthebrace.Thesyrinxeshavenotenlargedovertwoandahalfyears.Bothpatientscontinueconservativeorthopedicandneurosurgicaltreatments,followingthesyrinxeswithannualMRIscansandthescolioticcurveswithradiographs.CONCLUSIONS: WhilepreviousstudieshaverevealedgeneticlinkstoidiopathicscoliosisandtoChiariImalformationwithorwithoutsecondarysyringomyelia,thiscasesupportsthepossibilityofauniquegeneticlinktosyringomyeliawithsecondaryscoliosisandwithoutChiariI.Thisreportshouldencouragefurtherdocumentationoffamilymemberswithsyringomyelia,closemonitoringofpatient’simmediaterelatives,andfurtherresearchintothegeneticbasisofsyringomyelia.
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109. CEREBRAL VOLUMES AND DEVELOPMENTAL OUTCOMES IN PRETERM INFANTS WITH INTRAVENTRICULAR HEMORRHAGETimothyW.Vogel,MD;HassanAkbari,BA;PeterAnderson,PhD;MeredithEstep,PhD;YuningZhang,MS;DimitriosAlexopoulos,MS;LexDoyle,MD;DiegoMorales,MS;TerrieInder,MD;DavidLimbrick,MD,PhD(St.Louis,MO)INTRODUCTION: Intraventricularhemorrhage-(IVH)isacommonandsevereneurologicalcomplicationarisingfrompretermbirth,occurringin15-20%ofinfants.WhileinfantswithIVHsuffersignificantdevelopmentalimpairments,therelationshipbetweenregion-specificcerebralvolumesanddevelopmentaloutcomesintheaffectedchildrenremainsunclear.METHODS: Weperformedaretrospectivecase-controlanalysisofpreterminfantsreceivingMRIattermequivalent-(TE)age.InfantswereseparatedintothreegroupsbasedontheirIVHscores-(noIVH,GradeIorIIIVH,andGradeIII/IVIVH).Caseswerematchedbasedongender,gestationalage,andclinicalriskindexforbabies-(CRIB)scores.BrainvolumesweregeneratedforCSF,corticalgreymatter,myelinatedwhitematter,andunmyelinatedwhitematter.Brainregionswerealsofurthersubdividedinto8additionalanatomicregionsbasedonknownfunctionalstatus.Developmentaloutcomeswerecalculatedat2yearsofageusingBayleyScalesofInfantDevelopmentII-(BSID-II),andat7yearsofageusingtheMovementAssessmentBatteryforChildren-(MABC2).Outcomemeasureswerecomparedbetweenthethreegroupsusinganalysisofcovariates-(ANCOVA).RESULTS: HighgradeIVH-(gradeIII/IV)affectscerebralmorphology,causingsignificantlylargerrelativeorbitofrontalvolumeandCSFvolumedeterminedbyTEMRIscans-(p<.05).HighgradeIVHresultsinsignificantlysmallerpremotorbasalganglia,sensorimotormyelinatedwhitematter,andrelativeinferioroccipitalandcerebellarunmyelinatedwhitematterinpreterminfants-(p<0.03).CognitiveandmotorfunctioningwerelowerwithhighgradeIVH.CONCLUSIONS: TheobservedtrendofdecreasingcognitiveandmotorfunctionwithincreasingIVHgrademaybeassociatedwithchangesinregionalvolumesandventricularsizesecondarytoIVH.
110. CHANGING GLOBAL TRENDS IN SEIZURE OUTCOMES FOLLOWING RESECTIVE SURGERY FOR TUBEROUS SCLEROSIS IN CHILDREN WITH INTRACTABLE EPILEPSYGeorgeM.Ibrahim,MD;AriaFallah,MD;JamesRutka,MD,PhD(Toronto,Canada)INTRODUCTION: Tuberoussclerosis(TS)istheleadingcauseofgeneticepilepsyworldwide.Resectivesurgicalstrategies,whichmaymitigatethediseaseburdenbysecuringrelieffromseizures,haveevolvedconsiderablyovertime.Here,weevaluatechangesinseizureoutcomesfollowingresectiveepilepsysurgeryinchildrenwithTSoverthelast50years.METHODS: AsystematicreviewofliteraturewasperformedtoidentifystudiesreportingseizureoutcomesfollowingresectiveepilepsysurgeryinchildrenwithTS.Usinganindividualparticipantmeta-analysisapproach,seizureoutcomesandassociatedcovariateswerecombinedfromselectedarticles.FavorableseizureoutcomewasdefinedasEngelClassI-II.Multivariatelogisticregressionwasusedtodeterminesignificantassociationsbetweenseizureoutcomesandtimeofsurgery.RESULTS: Twentystudiesfrom1966topresent,yielding186participantsmetinclusioncriteriaforthestudy.Onmultivariateanalysis,adjustingforlengthoffollow-up,atrendtowardsimprovedseizureoutcomesfollowingresectiveepilepsysurgeryforTSwasobserved(OddsRatio[OR]0.52;95%ConfidenceInterval[CI]0.23-1.17;p=0.11).Inthelast15years,agreaterproportionofyoungerchildrenalsounderwentresectivesurgerycomparedtoprior(OR0.93;95%CI0.89-0.97;p<0.01).TherewerenosignificantdifferencesbetweenoutcomesinNorthAmericaandelsewhere(p=0.45).CONCLUSIONS: Anon-significanttrendtowardsimprovedseizureoutcomesfollowingresectivesurgeryforTSwasobservedfrom1966topresent.
111. CHIARI I MALFORMATION: OUTCOME, COMPLICATIONS AND PERIOPERATIVE MANAGEMENTSubashLohani,MD;MarieLightowler;R.MichaelScott,MD;LilianaGoumnerova,MD(Boston,MA)INTRODUCTION: ChiariImalformationisacommonconditionrequiringsurgicalmanagementwhenclinicallyindicated.Theperioperativemanagementmayincludepre-operativeandpost-operativelaboratoryevaluations,bloodavailabilityandovernightstayinanICUoracutecareunit.WereviewedourexperiencewithallsurgicalproceduresforChiariImalformationswithspecificattentiontocomplicationsrelatedtosurgery,lengthofstayandneedfordetailedpre-operativeevaluationtoprovideguidelinesforperi-operativemanagement.METHODS: RetrospectivereviewofallpatientswithsurgicaldecompressionforChiariImalformationwasperformedoverthepast5years.Financialdatafromthehospitalwasobtainedwithrespecttothecostassociatedwithlaboratoryinvestigationsandpost-operativehospitalstay.RESULTS: Therewereatotalof272patients.Therewasnosignificantabnormalityinroutinepre-operativelabstudies.Bloodlosswas45.5mLinaveragewithoneinstanceof400mLbloodlossneedingRBCtransfusion.Post-operativelyallbutnineweremanagedonthefloor.Averagedurationofpost-operativedexamethasoneusewas4.3days.Averagelengthofhospitalstaywas3.5days.Therewere9complications.Onepatientdevelopedhydrocephalusrequiringshunting.CONCLUSIONS: SurgicaldecompressionforChiariImalformationhasalowrateofpost-operativecomplicationsandiseffectiveinalleviatingtheassociatedclinicalsymptoms.Routinebloodworkisnotindicatedandpost-operativemanagementinmostcasesdoesnotrequireadmissiontoanICUoracutecareunit.
112. CHIARI TYPE 1 MALFORMATION AND SYRINGOMYELIA: RISK FACTORS FOR DEVELOPMENT OF SPINAL DEFORMITYJakubGodzik;DavidKim,BA;MichaelKelly,MD;JeffreyLeonard,MD;MatthewSmyth,MD;TSPark,MD;DavidLimbrick,MD(St.Louis,MO)INTRODUCTION: TheassociationofspinaldeformityandsyringomyeliainchildrenwithChiariTypeIMalformation(CIM)iswelldescribed,butthenatureofthisrelationshipremainsunclear.Inthecurrentstudy,wesoughttoquantitatetherelationshipbetweensyrinxsizeandspinaldeformityinthispopulation.METHODS: Medicalrecordsfromasingleinstitutionwerequeriedforindividuals<18yearswithCIM-associatedsyringomyelia(2001-2011).Subjectswithspinedeformitywereidentifiedusingstandardcriteriaonradiograph,CT,orMRI.Univariateandstepwisemultivariatelogisticregressionanalyseswereutilizedtoassesstherelationship.RESULTS: Ninety-foursubjectswithCIMandsyringomyeliawereidentifiedinthestudyinterval.Atotalof41(44%)patientswerefoundtohavespinedeformity,23(56%)ofwhichcarriedapreviousdiagnosisofdeformity,and18(44%)werediagnosedduringworkupfortheirpresentingsymptoms.Multivariateregressionanalysisidentifiedsyrinxwidth(OR1.388,CI95%1.151-1.673,p=0.001)andtonsillarherniation(OR0.875,CI95%0.767-0.997,p=0.044)assignificantlyassociatedwithdiagnosisofspinedeformitywhencontrollingforage,gender,andsyrinxlocation.ROCanalysisdemonstrated82.5%sensitivityand60%specificityforpresenceofspinaldeformitywithsyrinxwidthgreaterthanorequalto5mm.CONCLUSIONS: TheresultsfromthisstudydemonstrateapositiveassociationbetweensyrinxcharacteristicsandthepresenceofspinaldeformityinpatientswithCIM.Thepredictivevalueofimagingparametersmayofferguidanceinmanagementofpatientsathigherriskofspinaldeformityandfosterimprovedcommunicationbetweenorthopedicandneurosurgicalhealthproviders.
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113. COMPLICATION AVOIDANCE DURING RESECTION OF FOURTH VENTRICULAR BRAIN TUMORS WITH BRAIN STEM INVASION: VALUE OF INTRA-OPERATIVE EMG MAPPING OF FACIAL COLLICULUS IN PRESERVATION OF FACIAL NERVE FUNCTION IN PEDIATRIC PATIENTSSamerK.Elbabaa,MD,FAANS(St.Louis,MO)INTRODUCTION: Microsurgicalapproachestotherhomboidfossaforresectionoffourthventriculartumorscarryrisksoflowercranialneuropathiesincludingpermanentfacialpalsy,especiallyincasesofbrainsteminvasion.MultiplereportslookedatEMGmappingoffacialcolliculusandsafeentryzonesintointrinsicbrainstemtumors.Wereviewourexperienceandfacialnervefunctionaloutcomeswithpediatricfourthventriculartumorswithbrainsteminvasion.METHODS: Retrospectivereviewofoperativenotes,MRIimagesanddocumentedpre-andpost-operativefacialnervefunctionaloutcomesinpediatricpatientswhounderwentEMGfacialresponsemappingduringmicrosurgicalresectionoffourthventriculartumorswithbrainsteminvasion.RESULTS: Sixchildrenwereidentified.Agerange(2-16years),averageage9.1years.Therewere3medulloblastomas(2classic,1anaplastic)and3pilocyticastocytomas(JPA).AlltumorswereconfirmedtobeinvadingthebrainstemonintraoperativegrossfindingsoronpreoperativeMRIimaging.Afterresectionoffourthventricularcomponentofthetumor;EMGmappingoffacialcolliculusoneachsidewasperformedusingdirectstimulationfollowedbyresectionofbrainstemcomponentaccordingtoEMGfindings.Averagefollow-upwas6months.Post-operativeMRIimagingrevealedgrosstotalresectionin5patientsandneartotalresectionin1patientwithJPA.Averagepre-operativeHouse-Brackmann(HB)scoreoffacialnervefunctionwas1.5(range1-3)andaveragepost-operativescorewas1.5(range1-4).AllpatientshadimprovedorstableHBscore,except1patient.CONCLUSIONS: Inoursmallseries,brainstemEMGmappingoffacialcolliculusprovestobeavaluabletoolinpreservingfacialnervefunctioninpediatricpatientswithfourthventriculartumorswithbrainsteminvasion.
114. COMPLICATIONS OF PEDIATRIC CRANIOPLASTY: A SYSTEMATIC REVIEWKaushikAmancherla,BS;BrandonG.Rocque,MD,MS;SandiLam,MD(Madison,WI)INTRODUCTION: Cranioplastyfollowingdecompressivecraniectomyisroutinelyperformedinbothadultandpediatricpopulations.Evidenceintheadultpopulationsuggeststhatthisprocedureisassociatedwithhigherratesofcomplicationsthanelectivecranialsurgery.Thisstudyisareviewoftheliteratureassessingfactorsthataffecttheriskofcomplicationaftercranioplastysurgeryinpediatricpatients.METHODS: AsystematicsearchofPubMed,Cochrane,andSCOPUSdatabaseswasundertaken.Studiesassessingtimingofsurgery,boneflapstoragemethod,timetoreimplantation,materialused,orcomplicationrateswereselectedforfurtheranalysis.RESULTS: Articleswerescreenedbasedontitleandabstract.Outof20studiesinvestigatingtheincidenceofcranioplastycomplications,9focusedonapediatricpopulationandwereincludedinthisanalysis.Theincidenceofboneresorptionfollowingcranioplastywasreportedinsevenstudiesandrangedfrom7.4%to50%.Theincidenceofpost-operativeinfectionrangedfrom6.56%-21.4%,asreportedinthreearticles.Consideringthelimitednumberofarticlesandthesmallsamplesizesinvolved,thereisinsufficientdatatodrawanymeaningfulconclusionsregardingriskfactorsthatpredisposepediatricpatientsundergoingcranioplastytoboneresorptionorinfection.CONCLUSIONS: Thereisapaucityofstudiesassessingoutcomesandcomplicationsfollowingcranioplastyinchildrenandadolescents.Thereislittleevidencetosuggestthatmethodofflappreservation,timingofsurgery,materialused,ortimetoreimplantationhasaninfluenceontheincidenceofcomplications.Largerstudies,bothprospectiveandretrospective,areurgentlyneededinordertoshedmorelightonthisimportantissue.
115. CONGENITAL DERMAL SINUS WITH AN INFECTED DERMOID CYST IN CERVICO-THORACIC SPINAL CORDBrianLee,MD;YasserJeelani,MD;J.GordonMcComb,MD(LosAngeles,CA)INTRODUCTION: Congenitaldermalsinuses(CDS)areepithelium-linedtractsthatresultfromincompleteseparationofcutaneousectodermfromtheunderlyingneuroectoderm.CDSmaybeassociatedwithdermoidcystsandcancausecomplicationsbymasseffect&byfunctioningasapathwayforinfection.Cervicalandthoracictractsarerare,makingup1%and10%ofallCDS.METHODS: Wepresentanunusualcaseofacervico-thoracicCDSwithconcomitantinfecteddermoidleadingtoneurologicaldysfunction.RESULTS: Aone-year-oldmalewithanormaldevelopmentalhistorypresentedwithaseveralweekhistoryofprogressiveweakness.Previousvisitstotwooutsideemergencydepartmentsdiagnosedthepatientwithacuteotitismediaforwhichhehadtwocoursesofantibioticswithnoimprovementinsymptoms.Afteranotherepisodeoffeverandworseningofneurologicalsymptoms,thepatientwascorrectlydiagnosedashavingCDSwithaninfecteddermoidcyst.Antiobioticswereinitiated,thelesionwasresectedandthepatientimprovedneurologically.CONCLUSIONS: AlthoughcervicalandthoracicCDSwithinfecteddermoidsarerare,oneshouldhaveahighindexofsuspicionwhencutaneousstigmataofspinaldysraphismareidentified.Duetotheriskofneurologicaldeterioration,therecommendedtreatmentofCDSwithorwithoutaconcomitantintraspinaldermoidispromptadministrationofantibioticsanddefinitivesurgicalintervention.
116. CONGENITAL OS ODONTOIDEUM ARISING FROM THE SECONDARY OSSIFICATION CENTER WITHOUT PRIOR FRACTUREBrianJeffreyMcHugh,MD;RyanGrant,MD;MichaelDiluna,MD(NewHaven,CT)INTRODUCTION: Theetiologyofosodontoideumhasbeendebatedintheliteraturesinceitwasinitiallydescribed.Herewepresentacaseofosodontoideum,reviewtheliterature,andproposethattheetiologyofosodontoideumismultifactorialandrelatedtotheembryologyandvascularsupplytotheodontoidprocess.METHODS: Wepresentthecaseofafour-yearoldfemalewithosodontoideumandatlantoaxialinstabilityafteramotorvehiclecollisionandconductacomprehensivereviewoftheavailableliteraturefocusingontheevidencesupportingcongenitalversustraumaticetiology.RESULTS: Flexion-extensionviewsdemonstratedatlantoaxialinstabilitywithanatlantodentalinterval(ADI)of15mmonflexion.CTscanshowsawell-corticatedbonyossicleconsistentwithosodontoideumandMRIshowsnoacutebonyorligamentousinjuryandanormalspinalcord.CTimagingperformedthreeyearsearlierdemonstratedanincompletelyossified,cartilaginous,orthotopicosseparatedfromthebodyoftheodontoidprocessatthelevelofthesecondaryossificationcenterwithashortodontoidprocess.Thiscasepresentstheearliestimagingdemonstratingthepresenceofacongenitalorthotopicosodontoideumatthesecondaryossificationcenter.However,availableliteraturesupportsbothcongenitalandtraumaticetiologies.CONCLUSIONS: Mostdescriptionsosodontoideumpre-datethemoderneraforradiographicwork-upofcraniocervicalpathology.Wedescribeacongenitalosodontoideumwithcraniocervicalinstability,withoutCTevidenceofaninitialfractureatpresentation,threeyearsprior.Wesupportamultifactorialetiologyofosodontoideumandproposethatthedensrequiresabalancebetweenembryologicsegmentaldevelopment,anatomicalignment,andbloodperfusion.
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117. CONSERVATIVE MANAGEMENT OF CHIARI MALFORMATION IN CHILDHOOD TRANSVERSE MYELITISSudhakarVadivelu,DO;DanielBecker,MD;AkashPatel,MD;SabihEffendi,MD;SohumDesai,MD;AndrewJea,MD;WilliamWhitehead,MD;ThomasLuerssen,MD;RobertDauser,MD(Houston,TX)INTRODUCTION: Abruptonsetofmyelopathyinvolvingascendingbilateralmotorandsensorynervedistributionswithautonomicdysfunctioncanbeseenfollowingrecentcommunityacquiredinfectionintransversemyelitis.Fewcasesmaypresentwithincidentalchiarimalformation.Nopreviousreportshaveidentifiedthisassociation.Wedescribetheassociationoftonsillarectopiaandtransversemyelitis,managementpatternsandillustrateselectcaseswhereregressionoftheacquiredchiarimalformationoccurred.METHODS: Betweentheyearsof2006-2012,weretrospectivelyreviewedatwocenterexperiencewithchildhoodcasesoftransversemyelitisreferredwithchiarimalformation.Atotalofninepatientswereidentifiedanddemographic,anatomical,andoutcomecharacteristicswereexamined.RESULTS: Duringthe6-yearperiod,childrenpresentingwithtransversemyelitisandnotedtohavechiarimalformationrangedinagefrom9mosto7yearsofageandpresentedwithadocumentedhistoryofrecentcommunityacquiredinfection.Radiographicevidenceofspinalcordedemainallcasesappearedinthecervicalspine,withfewcasesextendingtothethoracicspineandwithoutT1indicesconsistentwithcysticcavitation.Inallcases,theacquiredchiarimalformationwastreatedconservatively.Intwocases,weobservedregressionofectopiaandinnoneofthecaseswasthereprogressiontowardscranialneuropathies,hydrocephalusorsyrinxformation.CONCLUSIONS: TransversemyelitiscanbeassociatedwithacquiredChiarianomaliesinselectcases.Asymptomaticchiarimalformationscanbemanagedconservatively,andinfewcasesobservedwithregressionaftersteroidtreatmentfortransversemyelitis.
118. CRANIOCEREBRAL DISPROPORTION (CCD) AS A COMPLICATION OF SHUNTED HYDROCEPHALUS: A SERIES OF TWO PATIENTS AND PROPOSAL FOR A RATIONAL DEFINITION, DIAGNOSIS, AND TREATMENT PROTOCOLAdamLanceSandler,MD;LawrenceDaniels,MD;DavidStaffenberg,MD;EliezerKolatch,BA;JamesGoodrich,MD,PhD;RickAbbott,MD(Bronx,NY)INTRODUCTION: Theshuntedchildwhosuffersfromchronic,debilitatingheadachesdespiteafunctioningshuntrepresentsadiagnosticandtherapeuticchallenge.Thenotionthatasubsetofsuchchildrenmaybesufferingfromamismatchbetweenthefixedintracranialvolumeandthegrowingbrainhasbeenofferedasoneexplanationfortheseproblematicheadachessincethemid1970s.Thelackofareliable,reproduciblemethodtodiagnosethiscondition,however,hashamperedattemptstotreatitappropriately.Furthermore,forthosepractitionerswhobelievethatthefundamentalproblemwiththesepatientsisnotanincongruencybetweenCSFproductionandabsorptionbutratheradiscrepancybetweenthevolumeoftheintracranialcontentsandtheavailableintracranialspace,thelackofagreed-upontherapeuticendpointsforcranialvaultexpansiontechniqueshaslimitedtheuseofsuchtechniquesintreatingthisentity.METHODS: Heretheauthorspresentaconcisedefinitionofcraniocerebraldisproportion(CCD),basedprimarilyonthetemporalcorrelationofplateauwavesonIntracranialpressure(ICP)monitoringwithheadacheexacerbation,andsecondarily,onvariousradiographicsigns.AtechniqueofexploitingcontinuedICPmonitoringduringprogressivecranialexpansionisdescribedwherebythegoalofexpansionisdefinedasthecessationofplateauwaves.RESULTS: Tworecentcasesinwhichthisprotocolwasemployedsuccessfullyarepresented.CONCLUSIONS: TheevidenceforCCD--;anatomic,pathologic,histologic,radiographic--;isrobustandcannolongerbeseriouslydenied.Problemsofunder-expansionencounteredpreviouslymayberesolvedthroughthesimultaneousutilizationofICPmonitorsandREDIIrigidexternalcranialvaultdistractors.
119. WITHDRAWN
120. DECOMPRESSIVE HEMICRANIECTOMY FOR ISCHEMIC STROKE IN THE PEDIATRIC POPULATIONSacitBulentOmay,MD;MichaelFu;GrantRyan,MD;MichaelDiluna,MD;CharlesDuncan,MD;KetanBulsara,MD(NewHaven,CT)INTRODUCTION: Decompressivehemicraniectomy(DH)isnowincreasinglyconsideredasbeneficialtherapyforstrokepatientswithunilateralhemisphericedemaafterfailedconservativemanagementintheadultpopulation.Nomajorstudyhasyetaddressedthistopicinpediatricpopulation.METHODS: AliteraturereviewofpediatricDHforstrokewasperformed.RESULTS: Intotal,11patientswerereported.Allhadsatisfactoryoutcomesexceptonewhohadadominanthemisphereinfarction.Twootherchildrenwithdominanthemisphereinfarctionshavenoresiduallanguagedeficit.CONCLUSIONS: OurobservationsinreviewingthesecasessuggestthataDHcanbeofbenefitinhemisphericstrokeinchildrenafterfailureofmaximalmedicalmanagement.DHshouldbepartofthearmamentariumintreatingpatientswhohavefailedmaximalmedicalmanagement.Properlydesignedprospectivestudiesinthepediatricpopulationareneededtodetermineoptimaltimingandpredictorsforbestoutcome.
121. DEVELOPMENT OF NQF MEASURE OF SHUNT MALFUNCTIONSarahC.Jernigan,MD;LilianaGoumnerova,MD;JayBerry,MD,MPH;DionneGraham,PhD(Boston,MA)INTRODUCTION: Shuntedhydrocephalushassignificantlong-termmorbidityandcostsassociatedwithitscomplications.BostonChildren’sHospitalsubmittedameasureofshuntmalfunctionratetoNQFthatcanbeapplieduniversallybasedonadministrativedata.METHODS: WetestedtheICD9codingalgorithmforshuntmalfunctionagainstactualshuntmalfunctionasdeterminedbymedicalrecordreviewwithintwochildren’shospitalswhichparticipateinthePHISdatabase.AllshuntproceduresatBCHwerereviewedandthealgorithmwasvalidatedatTexasChildren’sHospital.Thesensitivity,specificity,predictedpositivevalue(PPV),andpredictednegativevalue(PNV)werecalculatedoverallandwithineachinstitution.OurprimaryoutcomewasVPshuntrevisionwithin30daysofinitialplacement.SASwasusedforstatisticalanalysis.RESULTS: Amongthe106chartsreviewedatthetwoinstitutions,theICD9codingalgorithmcorrectlyidentified9ofthe12malfunctionsfoundbychartreviewresultinginasensitivityof0.75.Thecodingalgorithmhadhighspecificity(0.96)andalowfalsenegativerate(3%).PerformanceofthecodingalgorithmwasbetteratCHBthanTCH;howeverthedifferencesdidnotreachstatisticalsignificance,perhapsduetosmallsamplesizes.CONCLUSIONS: OurresultsdemonstratethatICD9-codedadministrativedatabases,suchasthePHISdataset,canbeusedtoevaluateVPshuntmalfunctionwithacceptablesensitivityandhighspecificity.Thehighspecificityofthealgorithmprovidesthedesirablepropertyofguardingagainstover-estimationoftheVPshuntmalfunctionrate.Thisisthefirstnationallyacceptedpediatricneurosurgeryqualityoutcomemeasure.
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122. DIAGNOSTIC ERRORS IN CRANIOSYNOSTOSISAlexandreCasagrandeCanheu,MD;SergioGeorgeto,MD;MarcosDias,MD;MarcioLehmann,MD;CarlosZicarelli,MD;FahdHaddad,MD(Cianorte,Brazil)INTRODUCTION: Craniosynostosisisacommonissueatpediatricneurosurgicaldailypractice.Howevergeneralneurosurgeonsalsodealpossiblywiththeseinfants.Thus,diagnosticerrorsincraniosynostosisplayanimportantrolethatmustbediscussed.METHODS: Case1:A8monthsboy,whoseparentsandpediatricianbothagreedaboutfrontalelongation.Thecasewasconductedbyageneralneurosurgeonwhodiagnosedtrigonocephaly,scheduledthesurgeryandnoticedthepediatricneurosurgeon.Lateronthepediatricneurosurgeonrealizedwasnotareallycraniosynostosis,andthesurgerywasruledout.Themetopicsuturewasopenedwithaslightclosureatthebasis,expectedatthisspanoflife.Case2:A6monthsboy,presentingamildfrontalelongation,withnokeenvisible.Theboywasreferredtothepediatricneurosurgeonbelievedtobeaboutsurgicalapproach.Imagesshowedcompleteclosureofthemetopicsuturewithnosignaloffrontalkeenbesidesmallfociofbilateralthinparietalbonesuggestingsomemesenchymaldisturbance.Nosurgerywasperformedoncethereisnorealcraniosynostosis.RESULTS: Theneurosurgeonmustbeawareandriseupsuspicionwhenevertheclinicalpictureorexamsdon’tshowtheclassicalfeaturesexpectedinthosecases.Sothepediatricneurosurgeonshouldbeconsultedeverysinceoneisdealingwithcraniosynostosis.Bothchildrendiscussedabovehadbeenoperatedoniftherewasn’tapediatricneurosurgeon.CONCLUSIONS: Especiallyindevelopingcountriesisnotsoeasytofindpediatricneurosurgeons.Theneurosurgicalteachingmustcontinuetogrowinordertoavoiddiagnosticerrorsandreckless.
123. DIAGNOSTIC MINI-ENDOSCOPIC VISUALIZATION: AN ADJUNCT IN DETERMINING THE NEED FOR OPERATIVE CHIARI RE-EXPLORATIONDavidM.Frim,MD,PhD,FAANS,FACS(Chicago,IL)INTRODUCTION: InaminorityofoperatedChiaripatients,symptomsdonotresolvepostoperatively.Re-evaluationwithMRItoassessforadequatesubarachnoidspace,withMRICINEflowtoassess4thventricularoutflow,andwithlumbarpuncturetoassessCSFpressure,aresometimesunrevealing.Wedescribeanendoscopictechniquethatcandeterminetheneedforopenre-operationinthissituation.METHODS: Technique:Patientsarepositionedpronewithheadflexioninpinfixation.A5-8mmincisionismadeovertherecapitulatedcisternamagnaspaceanddissectedtowardsthe4thventricle.A16gangiocatheteristhenplacedintotheCSFspacefollowedbya1.2mmdiagnosticendoscope.Directvisualizationof4thventricularoutflowismadeandifimpeded,thesurgerycanbeexpeditiouslyconvertedtoopenexplorationandre-decompression.RESULTS: Thistechniquehasbeenapplied6times.In3casestheendoscopyledtoopensurgeryrevealing4thventricularoutflowobstruction;re-decompressionresolvedtherecurrentsymptoms.Inthenegativeexplorations,patientswerereadyfordischargethefollowingmorningandreferredfornon-surgicaltreatments.CONCLUSIONS: Thedecisiontoperformre-operativeChiarisurgeryisacomplicatedone.Wedescribeaminimallyinvasiveendoscopicapproachthatallowsdirectvisualizationofpreviousdecompressionswhenothertestingisunrevealingandtheclinicalsituationcompelling.Applyingthistechniquedemonstratesthatdespitenegativeevaluationstherearepatientsthatwillbenefitfromre-decompression.Thistechniquecanalsodeterminewhenopenre-explorationisnotneeded.
124. DIFFUSION TENSOR IMAGING TRACTOGRAPHY AND FRACTIONAL ANISOTROPY IN PEDIATRIC SPINAL CORD PATHOLOGYBrianJosephKelley,MD;HelmuthGahbauer,MD;MichaelDiluna,MD;CharlesDuncan,MD;KeithHeberlein,PhD;GordonSze,MD(NewHaven,CT)INTRODUCTION: Diffusiontensorimaging(DTI)isanextensionofmagneticresonanceallowingfortractography.Fractionalanisotropy(FA)measuresthemolecularmotionofwaterandisquantifiedbetween0(isotropic)and1(anisotropic).DTIassistswithpre-operativeplanning,mostoftenforintracraniallesionresectionwhileFAservesasarelativeindicatoroftracthealth,withvaluescloserto1suggestingintactmyelin.Whilethesemodalitieshavebeenwidelyutilizedwithinadultpopulations,extensiontopediatricpatientshasbeenlessforthcomingespeciallywithinthecontextofspinalcordpathology.METHODS: PatientsundergoingspinalMRIreceivedadditionalDTIsequencesfromwhichtractographyandFAvaluesweregenerated.Post-operativeT1/T2images,tractography,andFAvalueswithinthecervicalregionofa10year-oldpatientwhopresentedwithChiariImalformationandsyrinxwerereviewed.T1/T2imageswereusedtolocalizethesyrinxandsuperimposeduponDTIsequencestoassistwithFAmeasurements.RESULTS: Tractographyrevealedlineartractsaroundthesyrinx.FAvaluesaboveandbelowthesyrinxservedasinternalcontrolsforintactcordwhilediminishedvalueswithinthesyrinxconfirmpathology.AreasimmediatelyadjacenttothesyrinxalsodemonstrateddiminishedFAvaluesdespiteconventionalT1/T2morphologysuggestingpathologynotappreciatedbystandardimaging.CONCLUSIONS: TractographyandFAvaluesmaybeusedtoevaluatepediatricspinalcordpathology.SerialimagingprotocolsutilizingDTIwillgeneratelongitudinaldatathatcomparesFAvaluesandmayhelpdirectoperativetreatmentforevolvinglesionssuchassyringomyelia,intramedullarytumors,andspinalcordinjury.
125. DOES HELMET USE PLAY A ROLE IN THE PATTERNS OF HEAD INJURIES IN PEDIATRIC DOWNHILL SKIIERS AND SNOWBOARDERS?ChristinaMiekoSayama,MD;JohnKestle,MD,MSC(SaltLakeCity,UT)INTRODUCTION: Downhill-skiingandsnowboarding-relatedheadinjury,helmetuse,andpatternofheadinjuryhavebeenstudiedinadultsbutsimilarstudiesarelackinginchildren.Wehypothesizethatthepatternofheadinjurydiffersforhelmetedversusnon-helmetedchildrenadmittedtothehospitalafteraskiing-orsnowboarding-relatedaccident.METHODS: Wereviewedtheprospectively-collectedtraumadatabaseofallchildrenadmittedtoPrimaryChildren’sMedicalCenterwithdiagnosisoftraumaticbraininjuryafteraskiing/snowboarding-relatedinjurybetweenJanuary2002andDecember2011.Helmetusewasrecordedandradiographicimaging(CTorMRI)reviewedforeachpatienttodeterminethepatternofheadinjury(SDH,EDH,SAH,contusion,skullfracture,pneumocephalus,ornegative).RESULTS: Therewere201patientsinourcohort,11wereexcludedbecausehelmetusewasnotrecorded.Ofthe101patientswearinghelmets;twowerenotedtohaveskullfractures(2%),11hadSAH/contusions(10.9%),andfourhadanEDH/SDH(3.9%).Ofthe89childrennotwearinghelmets;10hadskullfractures(11.2%),7hadSAH/contusion(7.8%),and5hadanEDH/SDH(5.6%).Wefoundthatthosewearingahelmetwere5.7times(95%CI1.54-;20.83)lesslikelytohaveaskullfracturethanthosenotwearingahelmet.TheincidenceoftraumaticSAH/contusion,SDH,andEDHwereotherwisesimilarinbothgroups.CONCLUSIONS: Helmetusesignificantlydecreasedtheincidenceofskullfractureinchildrenseeninthehospitalafteraskiingorsnowboarding-relatedaccident,howevertherewasnodifferenceinthepatternsofheadbleed.
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126. DOES RADIOTHERAPY-INDUCED REDUCTION IN TUMOR VOLUME TRANSLATE INTO LONGER SURVIVAL FOR CHILDREN WITH DIFFUSE INTRINSIC PONTINE GLIOMAS?YasserJeelani,MD;StefanBluml,PhD;BrianLee,MD,PhD;JoffreOlaya,MD;MarkKrieger,MD;J.GordonMcComb,MD(LosAngeles,CA)INTRODUCTION: WhilefocalradiationtherapytothebrainstemremainsthemainstayoftreatmentforDiffuseIntrinsicPontineGlioma(DIPG),adefinitiverelationshipbetweenradiation-inducedtumorsizereductionandenhancedsurvivalhasnotbeenobjectivelyestablished.METHODS: UnderanIRBapproval,aretrospectiveanalysisofallpatientswithadiagnosisofDIPGprimarilytreatedwithfocalradiationwithinthelast10yearswasundertaken.Manualsegmentationbytwodifferentexpertswasusedtomaptumorvolumes.RESULTS: 21patients(12female)mettheabovecriteria.Themedianageatdiagnosiswas7years.Allprimarilyreceivedradiation:30-33fractionsofIntensitymodulatedradiotherapy(IMRT)rangingbetween4500-6000cGywasadministeredoverameanperiodelapsedover40days.Concomitantchemotherapywasadministeredin12patients.Post-irradiationMRscanswereobtainedafterameanintervalof5weeks.Themediansurvivalwas11months(range:4-28months).Therewasnetreductioninlesionvolumein19patientsandintervalincreaseinsizein2.Intheformer,themedianpercentagereductionwas58%(+/-SD28)whereastheoverallmedianvolumetricreductionwas120.8cm3.Statistically,agreaterthan50%reductionintumorvolumewasassociatedwithasignificantlyimprovedsurvival(p=0.04).Themediansurvivaltimerangedfrom9.6mintumorsthatshowedlesserthan50%reductionto11.3minthosewitha<50%reduction.Thepresenceorabsenceofconcomitantchemotherapy,whenanalyzedindependently,wasnotastatisticallysignificantfactorforincreasedsurvival.CONCLUSIONS: Aradiation-inducedreductionintumorvolumebyafactorgreaterthan50%maymodestlyprolongsurvivalinchildrenwithDIPGs.
127. DOES THE POST-OPERATIVE PRESENCE OF AN ENHANCING CYST WALL IN PILOCYTIC ASTROCYTOMA INDICATE HIGHER RISK OF TUMOR RECURRENCE?ChristineBui;YasserJeelani,MD;JohnGrimm,MD;AndrewYousef;StephanieDaSilva,BA;J.GordonMcComb,MD;MarkKrieger,MD(Irvine,CA)INTRODUCTION: Debateexistsastotheneedtoresectenhancingcystwallsinchildrenwithpilocyticastrocytoma(PA).Thisstudyaimstoestablishwhetherpost-operativeresidualenhancingcystwallsinPAsareassociatedwithaworseprognosis.METHODS: AnIRB-approvedretrospectiveanalysiswasperformedonchildrentreatedforcysticPAatasingleinstitutionbetween2000and2012.Bothpre-andpost-operativeMRIswereanalyzedforthepresenceofanenhancingcystwall.RESULTS: 51children(27male)presentedwithcysticPA(10supratentorial;41infratentorial).Themedianageatdiagnosiswas8.8years(range:2.7-16.9).Meanfollow-upwasover4years(range:1month-10years).31patientspresentedwithenhancingcystwalls;postoperatively,13/31(42%)hadresidualenhancingcystwall.Overall,13/51patientshadtumorprogression/recurrence.In12/13cases,progressionoccurredatthesiteofgrossresidualtumor.7patientswithgrosstotalresectionofthesolidtumorandpostoperativeenhancingcystwallswerefollowedforanaverageofover3yearswithouttumorrecurrenceorprogression.UsingFisher’sexacttest,therewasnostatisticallysignificantrelationshipbetweenthepresenceofanenhancingcystwallpost-opandtumorrecurrenceorprogression.CONCLUSIONS: Residualcystwallisnotariskfactorfortumorrecurrence.Thegoalofsurgeryshouldbetoresectthesolidtumor.Thereisnoneedtosurgicallyresectthefullextentoftheenhancingcystwall.
128. ENDOCRINE OUTCOMES AFTER SURGERY FOR PEDIATRIC CRANIOPHARYNGIOMATeneA.Cage,MD;AaronClark,MD,PhD;DerickAranda,MD;AndrewParsa,MD,PhD;PeterSun,MD;KurtisAuguste,MD;NalinGupta,MD,PhD(SanFrancisco,CA)INTRODUCTION: Currently,thereisnoconsensusontheoptimalmanagementforcraniopharyngioma.Thereisdifficultyachievingabalancebetweenreducedrecurrenceratesandacceptablemorbidity.Weexaminedendocrinedysfunctionfollowingcraniopharyngiomatreatmentinpatientswhohadvaryingdegreesofresectionandadjuvantradiationtherapy(XRT).METHODS: Weperformedasystematicreviewoftheliteratureofpediatricpatientswithhistologicallyconfirmedcraniopharyngiomas.Post-operativeendocrineoutcomesweremeasuredwithrespecttoextentofresection(EOR)includingbiopsy,subtotalresection(STR)withorwithoutXRT,andgrosstotalresection(GTR).Chi-squarewasusedtocompareoutcomes.LogisticregressionwasusedtodetermineoddsratiosforoutcomesbyEOR.RESULTS: Disaggregateddatafrom109peerreviewedarticlesresultedin531subjects.Ofthese,348subjectshaddocumentedpost-operativeendocrineoutcomes.AfterGTR,patientshadhigherratesofadrenalinsufficiency,hypothyroidism,anddiabetesinsipiduscomparedtoSTR(p=0.01,p=0.04,andp=0.009).WhencomparingGTRtoSTRwithadjuvantXRT,GTRwasassociatedwithhigherratesofadrenalinsufficiency,hypothyroidism,anddiabetesinsipidus(p=0.03,p=0.03,andp=0.05).WhenXRTwasaddedasanadjuncttherapytoSTR,therewasanincreasedrateofpanhypopituitarism(p=0.003).CONCLUSIONS: WesuggestthatagreaterEORisassociatedwithagreaterriskofendocrinedysfunction.Inaddition,whenadjunctXRTisusedafterSTR,itisassociatedwithincreasedriskofpituitarydysfunction.Despitelimitationsofaretrospectivereviewoftheliterature,thisstudysuggeststhathigherratesofendocrinedysfunctionareassociatedwithagreaterEORoruseofadjuvantXRT.
129. ENDOSCOPIC THIRD VENTRICULOSTOMY WITH CHOROID PLEXUS CAUTERIZATION IN PREMATURE INFANTS WITH POSTHEMORRHAGIC HYDROCEPHALUSRickyH.Wong,MD;PeterWarnke,MD;DavidFrim,MD;SandiLam,MD(Chicago,IL)INTRODUCTION: Thereisgrowingliteratureshowingthatendoscopicthirdventriculostomy(ETV)withchoroidplexuscauterization(CPC)isaneffectivetreatmentforhydrocephaluseveninyoungpopulations(<1yearofage)withcertaindiagnoses,thoughtheviabilityofthisprocedureinprematureinfantswithposthemorrhagichydrocephalushasyettobefullyexplored.METHODS: Wereportonaretrospectiveseriesof5prematureinfantswithposthemorrhagichydrocephalustreatedwithETV/CPC.RESULTS: Fiveprematureinfants(averagegestationalage25.5weeks,range22.7weeksto28.9weeks)withGrade3or4IVHandhydrocephaluswithdemonstratedneedforCSFdiversion.FourweretreatedwithETV/CPC,whilethefifthwastreatedwithCPCaloneduetopoorvisualizationfromfriableependyma.AveragecalendarageatETV/CPCsurgerywas13.7weeks,range11to17.5weeks.All5patientshadaperiodofimprovementfollowedbyprogressivehydrocephalusrequiringpermanentshuntingrelativelyearlyinthepostoperativeperiod(averagecalendarageof24.3weeksatshuntimplantationsurgery,range20to34weeks).CONCLUSIONS: AllprematureinfantswithposthemorrhagichydrocephalusinthisseriesfailedETV/CPCanaverage8.5weekspostoperativelyandrequiredanothersurgeryforCSFdiversion.ThepathophysiologyneedstobefurtherexaminedtounderstandpredictorsofsuccessandthetimeframetofailureintheseveryyoungneonatalICUinfants.Largerscalestudiesareneeded.Initialresultsinthisseriessuggestthatshuntfreedommaynotbereadilyattainableinthispatientpopulation.
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130. ENDOSCOPIC FENESTRATIONS FOR SUPRASELLAR ARACHNOID CYSTSEliasB.Rizk,MD;ShaneTubbs,PhD;JerryOakes,MD;JohnWellons,MD,MSC;JoshuaChern,MD;JamesJohnston,MD,MSC;CurtisRozzelle,MD;JeffreyBlount,MD(Harrisburg,PA)INTRODUCTION: Theendoscopictreatmentofasuprasellararachnoidcyst(SAC)consistsmainlyofventriculocystostomy(VC)andventriculocystocisternostomy(VCC).TheauthorsreportontheeffectivenessofendoscopicVCforSACs.METHODS: TheauthorsretrospectivelyanalyzedthesurgicalresultsofpatientswithaSACtreatedusingendoscopicfenestration.Thepatientchartswerereviewedforclinicalpresentationsandclinicalandradiologicoutcomesbetween1993-2010.RESULTS: 11patientswereconsecutivelytreatedusingendoscopicfenestrationattheChildren’sHospitalofAlabama.Ageatpresentationrangedbetween4.5monthsto11years.Adolescentpatientspresentedwithheadacheswhileinfantshadeithermotordelayorincreasedheadcircumference.Cystvolumewascalculatedusingtheformulatocalculatethevolumeofanellipsoid4/3π;(A/2)(B/2)(C/2),whereA,B,andCarethethreediameters.Ifπ;isestimatedtobe3,thenthevolumeofanellipsoidbecomesABC/2.Nosignificantchangedoccurredinthesizeofthecystonfollowupimaging.Allpatientshadslowingofheadcircumferencegrowthandresolutionoftheirpresentingsymptoms.Noneofthepatientsdevelopedpostoperativecomplications.CONCLUSIONS: Endoscopicmanagementtotreatsuprasellararachnoidcystsisaviableandsafeoptioninthemanagementofthesecongenitalmalformations.
131. ENDOSCOPIC REMOVAL OF AN INTRAVENTRICULAR PNET TUMOR: RETRIEVAL OF A FREE-FLOATING FRAGMENT USING UROLOGIC BASKET RETRIEVERScottZuckerman,MD;KevinCarr,BS;LukeTomycz,MD;MatthewPearson,MD(Nashville,TN)INTRODUCTION: Theendoscopicresectionofintraventriculartumorsrepresentsauniquechallengetotheneurologicalsurgeon.Theseneoplasmsareinvesteddeepwithinthebrainparenchymaandaresituatedamongneurologicallyvitalstructures.Additionally,thecerebrospinalfluidsystempresentsadynamicpathwayforresectedtumorstobemobilizedandentrappedinotherregionsofthebrain.METHODS: In2011,wetreateda3yearoldfemalewithathirdventricularmassidentifiedonstereotacticbrainbiopsyasaWHOGradeIVtumor.Aftersuccessfulneoadjuvantchemotherapy,endoscopicsurgicalresectionwasperformed.RESULTS: Despitesuccessfulresectionofthetumor,theoperationwascomplicatedbymobilizationoftheresectedtumorandentrapmentintheatrialhornofthelateralventricle.Usingaurologicstonebasketretriever,wewereabletoretrievetheintacttumorwithoutadditionalcomplications.CONCLUSIONS: Theflexibilityaffordedbythenitinolurologicstonebasketwasusefulintheendoscopicremovalofafree-floatingintraventriculartumor.Thisdevicemayprovetobeusefulforotherpractitionersperformingthesecomplicatedintraventricularresections.
132. ETIOLOGY AND MANAGEMENT OF SYNDROME OF THE TREPHINED FOR PATIENTS WITH VP SHUNTSAtoTafarraWallace;BS;LukeTomycz,MD;KevinCarr,BS(Nashville,TN)INTRODUCTION: InpatientswhoaregivendecompressivehemicraniectomyfollowedbyventriculoperitonealshuntingforCSFmalabsorption,theskinflapcansometimesbecomesunkencoincidentwithneurologicaldeterioration.Thisuniquedisorder,likelyunder-reportedintheliterature,hasbeencharacterizedbysomeexpertsasthe“syndromeofthetrephined”.Thesepatientsarenotoriouslydifficulttomanage,maybehospitalizedfrequently,andtheiroptimaltreatmentcourseremainscontroversial.METHODS: Inthisstudyweexaminedtheclinicalcourseoftwopatientswhounderwentdecompressivehemicraniectomy,andsubsequentlyshuntedwithaprogrammableVPshunt,followingtraumaticbraininjury.Bothpatientsdevelopedthe“syndromeofthetrephined.”Theirtreatmentandoutcomewereconsidered,andrecommendationsweremadebasedonacomprehensivereviewoftheliterature.RESULTS: Bothpatientsexperiencedatumultuousclinicalcoursecharacterizedbymultiplehospitalizationsandepisodesofneurologicaldecline.Theircoursepresentationwasattributedprimarilytoover-shuntingandthepresenceofasunkenskinflap.Recoverywasverymarginalfollowingshuntreprogramming,butsymptomsdrasticallyimprovedaftercranioplasty.CONCLUSIONS: “Syndromeofthetrephined”isauniqueandlikelyheterogeneousconditionobservedinsomepatientswithcranialdefectswhoundergodecompressivehemicraniectomyandCSFshunting.Theconditionisprimarilyattributedtoasunkenskinflap,butherewepostulatethatshuntingmalfunctionissignificant.Shuntreprogramminginconcertwithcranioplastygenerallyprovidethecornerstoneinterventionsinthemanagementofthesedifficultpatients.Theetiologyoftheconditionandtherecommendedmanagementcourseforthesepatientswasdiscussed.
133. EVALUATING INFECTION TRENDS IN A PEDIATRIC ACUTE CARE FACILITYChevisShannon;StevenVeselsky;KyleAune;AmitaBey;AnastasiaArynchyna;JohnWellons,MD,MPH(Birmingham,AL)INTRODUCTION: Thisstudyevaluatestheresultsofamultidisciplinaryqualityimprovementinitiativetoreduceinfections.Wedescriberesultsofasingleinstitutionexperiencepre/postprotocolchanges.METHODS: Ataskforceoftendepartmentswasestablishedtoinvestigateanincreaseinneurosurgicalinfections.Thetaskforceidentified67institutionspecificvariablesassociatedwithinfection.Aretrospectivechartreviewofallpediatricneurosurgicalproceduresbetween2009and2012wasconducted.DatawasanalyzedusingSAS9.3.RESULTS: 1,127patients,undergoing2,282neurosurgicalprocedureswereidentified.Gestationalage,multipleadmissionsandlengthofstaywerestatisticallysignification(p<.0001).Prematureinfantswere2.5timesmorelikelytobeinfectedthanterminfants.Patientswithmorethan3admissionswere15timesmorelikelytobeinfectedthanpatientswithonlyonevisit.Patientsadmittedmorethan5dayswere8.2timesmorelikelytobeinfectedthanpatientsadmitted3daysorless.Oddsofdevelopinganinfectionwere3.2timeshigher(p<0.0001)foreachadditionalprocedureoccurringduringacontinuoushospitalstay.Infectionratespre/postprocesschangeswerenotstatisticallysignificant;however,wedonothaveadequatefollowupdatatoaccuratelydeterminethesignificancesurroundingprocesschanges.CONCLUSION: Aspreviousliteraturehasaddressed,theprematureinfantpopulationandincreasedlengthofstayleadstoincreasedriskofinfection.Ourstudyfurtherdefinedthesignificantriskassociatedwithhospitalstaysandmultipleprocedures.Wecontinuetoevaluateourpracticepatternstoinvestigateinstitutionspecificpredictorsofinfectionrisk.
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134. EVALUATION OF ATLANTO-OCCIPTAL DISLOCATION USING THE OCCIPITAL CONDYLE-C1 INTERVAL MEASUREMENT IN A PEDIATRIC LEVEL 1 TRAUMA CENTERColinJohnKazina,MD;WalavanSivakumar,MD;JayRiva-Cambrin,MD,MSC;DouglasBrockmeyer,MD(Winnipeg,Canada)INTRODUCTION: Atlanto-occipitaldislocation(AOD)isarelativelycommonprobleminpediatrictrauma.Theoccipitalcondyle-C1interval(CCI)measurementisusefulintheidentificationofpatientswithAOD.CCI’soflessthan2mmandgreaterthan4mmreliablydelineatenormalfromcraniocervicaldislocation,respectively.PatientswithintermediateCCImeasurements(2to4mm)aremorecomplex.WereportourexperiencewithdiagnosingandmanagingAOD,withemphasisonpatientswithintermediateCCImeasurements.METHODS: 33patientswereidentifiedashavingcraniocervicaldislocations.3patientsexpiredduringinitialresuscitation.6didnothaveCTscansavailableandwereexcludedfromanalysis.Patientsweredividedinto3CCIgroups:lessthan2mm,2to4mm,andgreaterthan4mm.Radiographicfindingsoftheintermediatemeasurementgroupwereanalyzedbymodality,withfusionastheprimaryoutcome.RESULTS: Ofthe24patientsreviewed,3hadbilateralCCImeasurementsoflessthan2mmand5hadbilateralCCImeasurementsofgreaterthan4mm.16patientshadintermediateCCImeasurements.Oftheintermediategroup,MRIswereavailablein15patients,andflexion-extensionx-raysofthecervicalspinewereavailablein5patients.MRIandflexion-extensionx-rayshavefalsepositiveratesof67%and50%respectively.CONCLUSIONS: InAODpatientswithintermediateCCImeasurements,MRIandflexion-extensionx-raysmaynotbereliableinassessingthetrueextentofoccipital-cervicalinstability.ThisdatasupportsthepremisethatCTwithCCImeasurementsshouldbetheprimarydeterminantindiagnosingAOD.
135. EXECUTIVE FUNCTION AFTER PEDIATRIC TBI: A SYSTEMATIC REVIEWShobhanH.Vachhrajani,MD;AshwinSankar,BS;AbhayaKulkarni,MD,PhD(Toronto,Canada)INTRODUCTION: Executivefunction(EF)encompassesmultiplecognitiveprocessesthatcontrolpurposeful,goaldirectedbehavior.EFdeficitsarecommonafterpediatrictraumaticbraininjury(TBI).WeperformedasystematicreviewoftheliteraturetoascertaintheprofileofEFdeficitsandpatternsofrecoveryafterpediatricTBI.METHODS: Medline,EMBASE,CINAHL,andPsycInfoelectronicdatabasesweresearched.Searchtermsincludedexecutivefunction,braininjuries,andpediatrics.Studieswithnon-TBIoradultpopulations,non-EFoutcomes,orwhereEFdatawasnotprovidedwereexcluded,aswereabstracts,bookchaptersandreviewarticles.QualityofevidencewasassessedusingtheGRADEframework.RESULTS: Of1261initialstudiesretrieved,88wereretainedforfulltextreview.Allwereprospectivecohortstudies,andwereofmoderatequality.MultiplemeasuresofEFwereused;directcomparisonofstudyresultswaschallenging.TBIpatientsshowedsignificantproblemswithsustainedandshiftingattention,inhibitioncontrol,planning,andproblemsolvingcomparedtocontrols.Thoseofyoungerage,severeTBI,andlowersocioeconomicstatusperformedpoorly.FunctionalMRIanddiffusiontensorimagingimplicatestherightdorsolateralfrontalcortexandgenuofthecorpuscallosum.EFdeficitspersist10yearsafterTBIbutlong-termrecoveryispossible.CONCLUSIONS: ChildrenshowsignificantEFdeficitsafterTBI,andareaffectedformanyyearsaftertheirinjury.Suchdeficitshavenotableimpactonsocialintegration,academicperformance,andthechild’sabilitytobesuccessfulinadulthood.Earlymultidisciplinaryinterventionisnecessarytopromoteoptimaloutcome.
136. FACTORS ASSOCIATED WITH HEMISPHERIC HYPODENSITY (HH) AFTER SUBDURAL HEMATOMA (SDH) FOLLOWING ABUSIVE HEAD TRAUMA (AHT) IN CHILDRENMatthewJacobRecker;KimberlyFoster,MD;MichaelBell,MD;PatrickKochanek,MD;P.DavidAdelson,MD;RobertClark,MD;ElizabethTyler-Kabara,MD,PhD(Duncansville,PA)INTRODUCTION: AbusiveheadtraumaisauniqueformofTBIwithincreasedmortalityandsequelae.HHafterSDHaffectinglargeareasofcortexhavebeendescribed(BigBlackBrain1).RiskfactorsforHHarenotunderstood.METHODS: WehypothesizedriskfactorscouldbeidentifiedforHH.ChildrenwithAHTadmittedtothepediatricICUwereenrolled.Records(prehospital,physiologicandradiologic)wereinterrogated.HHwasdeterminedbyablindedobserver.RESULTS: HH(n=13of24enrolled)wasnotassociatedwithage(15.4mo±3.3vs.12.1mo+/-;3.0)orinitialGCS(7.2+/–1.2vs.5.2+/–0.4).DailyPILOTscores(pediatricintensityleveloftherapy)anddailyICPmaxwerehigherinHH(p=0.01andp=0.037,respectively).Hypoxia(69.2%vs.27.3%),hypotension(23.2%vs.0%),andcardiacarrest(30.7%vs.9.0%)tendedtobegreaterinHH,asdidmortality(46.1%vs.18.1%).CONCLUSIONS: AvarietyofinsultsappeartobeassociatedwithHHafterSDH-intracranialhypertension,hypoxia,hypotension,andcardiacarrest.Classicneurosurgicalparamaters-initialGCS,pupillaryabnormality,initialradiographicfinding-donotpredictHH.Otherbloodproducts(epiduralhematoma,traumaticsubduralhematoma,intraparenchymalcontusion)donotcorrelate.Giventheprevalenceofthismorbidcondition,largerstudiestoidentifymechanismsandmitigatingclinicalapproachesarewarranted.1Duhaimeetal.,ProgBrainRes161:293-302,2007
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138. FEASIBILITY, SAFETY, AND INDICATIONS FOR SURGICAL BIOPSY OF INTRINSIC BRAINSTEM TUMORS IN CHILDRENTeneA.Cage,MD;SoniaSamagh,MD;SabineMueller,MD,PhD;TheodoreNicolaides,MD;DaphneHaas-Kogan,MD;MichaelPrados,MD;AnuBanerjee,MD;KurtisAuguste,MD;NalinGupta,MD,PhD(SanFrancisco,CA)INTRODUCTION: Diffuseintrinsicpontinegliomas(DIPGs)arerapidlyprogressiveandpathologicallyaggressivetumorsthatusuallyariseinchildren.Theiranatomiclocationmakesgrosstotalsurgicalresectionimpossibleandfewerthan10%ofpatientssurvivemorethantwoyearsafterdiagnosis.Intheabsenceofatissuediagnosis,treatmentplanningforchemotherapyorradiationcanbedifficult.Wereviewedtheresultsofsurgicalbiopsyofpontinetumorsinchildrenatasingleinstitutionandcomparedourresultstothoseavailableintheliterature.METHODS: Ahistoricalcohortstudywasperformedusingmedicalrecordsofpatientsundertheageof18whounderwentsurgicalbiopsyofanintrinsicpontinetumoratasingleinstitution.Fourteenpatientsunderwentstereotacticbiopsy,twohadopenbiopsies,andonehadanattemptedsurgicalresection.RESULTS: Tenmaleand7femalepatientswereincluded.Ageatpresentationrangedfrom8monthsto17years(average7.5years).Thepathologicdiagnosesofthetumorswerebothhighandlowgrade.Eightwerehighgrade(WHOgradeIIIorIV),8wereWHOgradeIItumors,and1wasapilocyticastrocytoma(WHOgradeI).Therewerenointraoperativecomplicationsandonlyonepatientdevelopedanewpost-operativeneurologicdeficit.CONCLUSIONS: Stereotacticbiopsyofbrainstemtumorsisadefinitivemethodforobtainingtissueforapathologicdiagnosisandisassociatedwithlowmorbidity.Thistechniquecanbeperformedsafelyandwillbeimportantfordirectingmultimodalityclinicaltrialsinvolvingchemotherapy,radiationtherapy,orotherbiologically-driventherapiesforchildrenwithintrinsicbrainstemtumors.
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140. GLIOMA EXOSOMES MODULATE LOW GRADE GLIOMA ANGIOGENESISPrajwalRajappa,MD;CaitlinHoffman,MD;YujieHuang,PhD;AyukoHoshino,PhD;JoonKim,BS;BrunoSilva,PhD;HectorSelgas,PhD;DavidLyden,MD,PhD;JeffreyGreenfield,MD,PhD(NewYork,NY)INTRODUCTION: WHOGradeIIgliomastransformintohighergradegliomasexhibitingneovascularization.Wepurifiedbraintumor-derivedexosomes,subcellularparticlescarryinggeneticmaterial.Exosomesarederivedfromtumorcells,fusewithastillundefinedpopulationofcellstosupporttumorgrowth.Weexploredtheirfunctionalroleanddescribehereanovelroleforexosomesinsupportingneoangiogenesisduringgliomatransformation.METHODS: TheRCASPDGF-drivenmodelwasusedtocreateaspontaneouslow-grademurineglioma.Tumor-bearingmicewereinjectedfor4weekswithpurifiedhigh-gradeglioma-derivedexosomes.Fusionofexosomeswithvarioustumor-associatedcellpopulationsincludingbone-marrowderivedcellswascharacterized.Flowcytometrywasusedtoquantifymyeloidandendothelialprecursorcellmobilizationandtoidentifytheirimmunophenotypes.Humanbrainendothelialandlow-gradegliomacelllineswereusedtoexaminetheeffectsofexosomesuponcellproliferation.RESULTS: MRIsaftera4-weekexosomeexposureperioddemonstrateheterogeneous,ring-enhancinglesionsinexosome-injectedanimalscomparedwithcontrols.Braincrosssectionsrevealhyperproliferativeandinvasivetumorsdemonstratingnewlyformedvasculature.Endothelialprecursorcellsaremobilizedperipherallyandatthetumorsite.Exosomesappeartopreferentiallyincorporatewithinmyeloid-derivedsuppressorcells(CD11b/GR1+).Humanbrainendothelialcellsandlow-gradeglialcelllinesproliferateextensivelywhenco-incubatedwithhumanhighgradeglioma-derivedexosomes.CONCLUSION: High-gradeglioma-derivedexosomesmaymediatecellularcross-talkbetweentumorsandamyeloid-derivedsubsetofimmunecells,promotingneovascularizationoflowgradegliomas.Thegeneticcargowithin,andspecificityoftheseexosomemediatedinteractionscontinuestobeexamined.
141. HAJDU-CHENEY SYNDROME AND BASILAR IMPRESSION: REVIEW AND CASE REPORTCristinaBarrena,MD;MikelArmendariz,MD;AliciaBollar,MD;AgustinNogues,MD;EnriqueÚrculo,MD(SanSebastian,Spain)INTRODUCTION: Hajdu-Cheneysyndromeischaracterizedbydissolutionoftheterminalphalanges,hearinglossandearlytoothloss.Thisprogressivecongenitalbonepathologyisabletoproduceoccipitocervicalinstability,foramenmagnumsyndromeandbasilarimpression.Neverthelessthispathologyisveryrareandnogeneralconsensushasbeenreachedaboutthemanagementofthesepatients.METHODS: Duetoacasereportinourdepartment,areviewismadewithcraniovertebraljunction,basilarimpression,Hajdu-Cheneysyndrome,osteochondrodysplasiasandacro-osteolysiskeywords.Management,clinicalprogressionandelectiontreatmentwastheobjectiveofourclinicalresearch.RESULTS: Anineyearsgirlisreportedwithhistoryofdevelopmentdelayandundeterminedsyndromiccharacteristicsince3yearsold.Neurologicalsymptomsbeganat9yearsoldwithataxiaandlowcranialnervepalsies.Onapreviousmagneticresonanceimaging,noseverebasilarimpressionwasseen,howeverthisskullbaseabnormalitywasevolutionated17monthslateralongwithprogressiveplatybasiaandtypeIchiarimalformation.Thesurgeryprocedurewas:externaltractionduringthreedays,occipitocervicalfixationwithposteriorcraniectomyandexternalimmobilizationusinghalobraceduringtwomonths.Radiologicalreductionandclinicalimprovementwereachieved.CONCLUSIONS: LittleisknownaboutnaturalhistoryofHajdu-Cheneysyndrome.Thecraniocervicalhallmarkofthesepatientsisbasilarimpressioncausedbysevereandprogressiveosteopeniaandbonedysplasia(mutationinNOTCH2).Adolescentstageistheintervaloftimeinwhichtheremaybeprogressionofbasilarimpression;consequentlycloselyfollowuphastobedonetopreventpotentiallydevastatingskullbasepathology.
142. IMAGING CHARACTERISTICS IN SYMPTOMATIC AND ASYMPTOMATIC CHILDREN WITH CHIARI 1 MALFORMATIONSanjivBhatia,MD,FAANS,FACS;MatthewGreen,BA;ORoberts,MD;ParthasarathiChamiraju,MD;JohnRagheb,MD(Miami,FL)INTRODUCTION: IncidentalChiariIMalformation(CIM)isoftennotedonMRIscansperformedforunrelatedreasons.Whilemostofthesechildrenareasymptomaticanddonotrequiresurgicalinterventionsomemaydevelopsymptomsonlongtermfollowup.AnatomicanddynamicMRimagingfeaturesrelatedtoCMIthatmaypredictthisriskarenotknown.METHODS: Clinicalrecordsof20asymptomaticchildrenwithCMIwithaninsignificantornosyrinxwerecomparedwithasecondgroupof20patientswithsymptomaticCMI.14ofthesepatientshadsignificantsyringomyelia.TheMRIdatareviewedincludedlevelofdescentandshapeofthecerebellartonsil,theamountofCSFsurroundingthetonsilandCSFflowattheforamenmagnum.RESULTS: Thepositionofthetonsilsvariedfrom5to20mmbelowtheforamenmagnuminbothgroups-13.3mm(mean)inthesurgicalgroupand11.7mm(mean)intheasymptomaticgroup.Inthesurgicalgroupthetonsilswerepointedin19andCSFflowwasnormalin7/20patients.Intheasymptomaticgrouptonsilswerepointedin16andCSFflowwasdiminishedin10/20patients.TheamountofCSFattheforamenmagnumwasdiminishedinallbutonepatientinthesurgicalgroup.CONCLUSIONS: NoindividualMRfindingcorrelatedwiththepresenceofclinicalsymptomsnorcoulditpredictthepresenceofasignificantsyrinx.AnMRbasedscoringsystemmayallowstatisticalanalysistoidentifyvariablesthatpredicttheriskofdevelopingsymptomsinasymptomaticChiaripatients.
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143. IMPROVEMENT IN HINDBRAIN CSF FLOW ON CINE MRI FOLLOWING EXTRADURAL DECOMPRESSION FOR CHIARI I MALFORMATIONMichaelDiLuna,MD;RyanGrant,MD,MS;VirginiaWaldrop,BA;AvitalPerry,BS(NewHaven,CT)INTRODUCTION: PosteriorfossadecompressionremainsthestandardsurgicaltreatmentforsymptomaticChiariImalformation,withimprovementinhindbrainCSFdynamicsseenoncineMRIfollowingintraduralopening.WeexaminedwhetherCSFflowdynamicsimproved,withcorrespondingsymptomatology,followingexclusivelyextraduraldecompression.METHODS: PatientsundergoingsurgeryforChiariImalformationunderwentpre-andpost-operativeCINEphase-contrastMRimaging.Theassociationofage,sex,tonsillarectopia,symptoms,syrinx,andHoffman’ssignwereassessedusingalogisticregressionmodeltocalculateoddsratioswith95%confidenceintervalsandChiSquaregoodnessoffittoassessformodelvariance.RESULTS: Mean+/-SDageattimeofsurgerywas29.8+/-14.0years.Eight(88.9%)ofthepatientshadimprovementinCSFflowoncineMRI,withallthesecasescorrelatingtoimprovedorresolvedsymptomatology.ThereliefofsymptomsorimprovementinCSFhindbrainflowdidnotfunctionasadegreeofage(OR=0.88[95%CI=0.67-1.16],p=0.37)ortonsilarectopia(OR=0.00[95%CI=0.00-0.00),p=0.99).Employinganinteractionmodelwitheachvariabledidnotproducestatisticalchange.Inmostinstances,intra-operativeCINEimages(iMRI)showedimmediateimprovementofCSFflowdynamicswithpurelyextraduraldecompression.CONCLUSIONS: ExtraduralposteriorfossadecompressionforChiariIimproveshindbrainCSFflowonCINEphase-contrastMRIwithacorrespondingreliefofsymptoms.Theseimprovementsarenotsecondarytopreoperativedemographics,tonsilarherniation,orneurologicalstatus.
144. INCIDENCE OF SEVERE IVH AND POST-HEMORRHAGIC HYDROCEPHALUS IN THE MODERN ERALukeTomycz,MD;AndreaBrock,BS;StevenSteele,RN;WilliamWalsh,MD;NoelTulipan,MD(Nashville,TN)INTRODUCTION: Intraventricularhemorrhage(IVH)continuestobeoneofthemaincausesofmorbidityandmortalityinprematureinfants.Wesoughttoidentifythescopeoftheproblemintheeraofmodernprenatalandneonatalcare.METHODS: Usinganestablishedinstitutionaldatabase,weidentifiedallthepreterminfants(EGA<40wks)bornatVanderbiltChildren’sHospital(VCH)fromJanuary2006toDecember2011.Weexcludedthosewithabirthweightover1500g,focusingonlyonthevery-low-birth-weight(VLBW)infantswhohaveaparticularpredispositiontointraventricularhemorrhage.Withinthiscohort,weidentifiedthesubsetofpatientswhorequiredtemporaryorpermanentCSFdiversion.AventricularaccessdevicewasusedfortemporaryCSFdiversionandaVPshuntwasusedforpermanentdiversion.SerialLPsandventriculo-subgalealshuntswerenotutilizedinanypatient.RESULTS: Atotalof1383preterm,VLBWinfantswereincludedinthestudy.Approximately35%oftheseneonatesdevelopedIVHofprematurity,and11.3%sufferedfromsevereIVH(GradeIIIorGradeIV).Atotalof25/1383(1.8%)developedpost-hemorrhagichydrocephalusrequiringaneurosurgicalinterventionfortemporaryorpermanentCSFdiversion.PresentedasafractionofthoseinfantswithGradeIIIorGradeIVIVH,25/157or15.9%oftheneonatesrequiredCSFdiversion.CONCLUSIONS: Improvedprenatalandneonatalcarehasdecreasedtheneedforneurosurgicalinterventionstotreatpost-hemorrhagichydrocephalusinpremature,VLBWneonates.
145. INTERACTIONS BETWEEN PROGRAMMABLE SHUNT VALVES AND THE IPAD 3 WITH SMART COVERYizhengHe;RoryMurphy,MD;JarodRoland,MD;DavidLimbrick,MD,PhD(St.Louis,MO)INTRODUCTION: InpatientswithprogrammableCSFshuntvalves,theriskofunintentionalvalveadjustmentassociatedwiththeenvironmentalmagneticinfluenceiseverpresent.WetestedwhetheraniPad3couldchangethepressuresettingsoftheStrataNSCAdjustablePressureValve,StrataNSCBurrHoleValve,StrataIIsmallvalve,SophysaPolarismodelSPV,andAesculapvalveproGAVbyusingdirectfluoroscopicvisualization.METHODS: Theleftfrontedge(LFE)oftheiPad3withsmartcoverhadthestrongestmagneticflux,measuringapproximately1200gauss.TheLFEwasfirstmovedlinearlyatapproximately30cm/soverthetestvalvefromvariousdirectionsatvariousdistances.ThentheLFEwasrotatedatvaryingdistancesabovethevalveatapproximately1radian/s.RESULTS: AlmostallshuntvalveswereimmunetoreprogrammingbytheiPad3atvaryingdistancesincludingdirectcontact.However,wefoundthatrotatingthepeakfluxlocationat4mmabovetheStrataIIsmallvalve,wewereabletochangethevalvepressuresettingseverytime.CONCLUSIONS: TheiPad3canchangepressuresettingsoftheStrataIIsmallvalveatadistancecomparabletothethicknessofcertainregionsofscalp.Althoughthespecificrotationalmotiondescribedhereislikelyrareinreallife,weneverthelessrecommendthatchildrenwithhydrocephalus,caregivers,educators,andtherapistsareinformedofthenow-apparentrisksofclosecontactwiththisincreasinglypopulartechnology.
146. INTRACRANIAL INFANTILE HEMANGIOPERICYTOMA: CASE REPORT AND REVIEW OF THE LITERATUREBrianJeffreyMcHugh,MD;JacobBaranoski,BS;AjayMalhotra,MBBS;AlexanderVortmeyer,MD;GordonSze,MD;CharlesDuncan,MD(NewHaven,CT)INTRODUCTION: IntracranialinfantileHemangiopericytomas(HPCs)arerarelesionsthatbehavelessaggressivelythantheiradultcounterparts.HerewepresentacaseofinfantileintracranialHPC,reviewtheliterature,andproposethatinfantileintracranialHPCsareinfactmisclassifiedcasesofinfantilemyofibromatosis.METHODS: Wepresentthecaseofa2montholdwithintracranialHPCandconductacomprehensivereviewoftheavailableliteraturefocusingontheevolvingconceptofwhatdefinesHPC,andhowthatmightrelatetoclinicalbehavior.RESULTS: Pre-operativeMRIdemonstratesaleftfrontalextra-axialmass(2.8x2.2x3.0cm),mildlyhypointenseonT1-weightedimagesandheterogenouslymildlyhyperintenseonT2-weightedimages.Thereismarkedbutmildlyheterogeneousenhancement,withmildspiculationoftheoutersurfaceofthetumoroncontrastimaging.Thetumorwasremovedenbloc.Histologicallythetumorishighlyvascularizedwithintermediate-sizedroundandspindle-shapedneoplasticcellswithpolymorphicnuclei.AsubsetoftumorcellsarepositiveforCD34,andnumeroustumorcellsarepositiveforbothsmoothmuscle-actinandmuscle-specificactinsuggestiveofmyofibromatousdifferentiation.At28monthspost-resection,MRIimagingrevealsnoevidenceofrecurrence.Additionallytheuniquefeatureofintralesionalextramedullaryhematopoeisiswasobserved.CONCLUSIONS: Whencomparedtotheiradultcounterpartsinfantilehemangiopericytomashavearelativelybenignclinicalcoursedespitetypicallyaggressiveappearinghistology.WeproposeinfantileintracranialHPCsrepresentanimmatureformofmyofibroblastic/pericyticlesionsofinfancy.Aso-called“true”HPC(immatureinfantilemyofibromatosis)hasbeendiscussedintheliteraturewithperipheralinfantileHPCs.
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147. INTRACRANIAL CYSTS AND SPORTS: EVALUATING THE RISK OF INJURYJenniferMaeStrahle,MD;MeleineMartinez;HughGarton,MD;KarinMuraszko,MD;CormacMaher,MD(AnnArbor,MI)INTRODUCTION: Intracranialcystsarefrequentlyfoundincidentally;howeverhavethepotentialtorupture.Itisunknownwhetherparticipationinsportsincreasestheriskforruptureorbleeding.METHODS: SurveysonsportparticipationwereadministeredtoconsecutivepatientswithintracranialcystsinpediatricneurosurgeryclinicattheUniversityofMichiganbetween12/2010and7/2012.RESULTS: 107patientswereincludedand79%weremale.Meanageatcystdiagnosiswas7.5years(-0.2-21)andageattimeofsurveywas9.7years(0-21).Therewere94patientswitharachnoidcysts,5withpinealcysts,5withmultiplearachnoidcystsand3withbothpinealandarachnoidcysts.Therewere107arachnoidcystsin102patientswith43%locatedinthemiddlefossaand33%intheposteriorfossa.19patientshadahistoryofsurgicaltreatmentfortheircyst.61(57%)patientsparticipatedin25differentsports,with54participatingincontactsports.Themostfrequentlyplayedsportsincludedsoccer(n=28),baseball(n=26),andbasketball(n=24).Thegroupparticipatedin508yearsofsportswithanaverageof8.61years/person,and4months/yearpersport.Therewasonecaseofarachnoidcystruptureafterafootballgameandonecaseofasubduralhematomainapatientwithanarachnoidcystafterheadingasoccerball.Bothpatientsfullyrecoveredanddidnotrequiretreatment.CONCLUSIONS: Complicationsofcystsinsportsappeartobelow,butfurtherprospectivestudyisneeded.
148. INTRAOPERATIVE MRI FOR CERVICAL SPINAL CORD TUMORSMarkDanielVanPoppel,MD;FrederickBoop,MD;AsimChoudhri,MD(Memphis,TN)INTRODUCTION: Intramedullaryspinalneoplasmresectionischallenging,requiringbalancebetweenthetherapeuticbenefitofgross-totalresection(GTR)andtheriskoffunctionaldeficits.IntraoperativeMagneticResonanceImaging(iMRI)hasbeensuccessfulintracranially,howevertheequipmentisnotdesignedtoguidespinalsurgery.Wereport2casesofintramedullarycervicalcordneoplasmsresectedusingamodifiediMRItechniqueforguidance.METHODS: TwopatientswithcervicalintramedullaryneoplasmsunderwentresectionwithiMRIguidance.Intraoperativeelectrophysiologicmonitoringwasperformedinbothpatients,withleadsdisconnectedpriortoMRI.Amodifiedcoilplacementtechniqueandheadpositioningwasdevelopedtofacilitateeffectiveimagingofthecervicalspine.Afteridentificationoftumormarginsandresectionofvisibleneoplasm,3TeslaiMRIwasperformedtoevaluateforresidualdisease.Real-timeconsultationwasperformedbetweentheneurosurgeonandtheneuroradiologist.RESULTS: Inpatientone,iMRIidentifiedresidualdisease,whichwasresected.SubsequentimagingdemonstratedGTR,includinga3monthpost-operativeexamination.Inpatienttwo,iMRIshowedgross-totalresectionofthecervicalintramedullaryneoplasmwithoutresidualtumor.Motorandsensoryfunctionwasstableinbothpatients.Pathologicdiagnosisinbothcaseswaspilocyticastrocytoma.CONCLUSIONS: 3TiMRIcanbesafelyperformedonthecervicalspineinpediatricpatientswithintramedullaryneoplasms.Theintraoperativeidentificationofresidualtumorcanimprovethechancesofagross-totalresectionwhileminimizingthechancesoffunctionaldeficits.ModerniMRIsetupsallowstandardinstrumentationtobeusedduringresection,includingtheuseofelectrophysiologicmonitoring.
149. INTRAOPERATIVE CONFIRMATION OF ACCURATE VENTRICULAR CATHETER PLACEMENTTylerS.Auschwitz,MD;FrederickBoop,MD;PaulKliom,MD,MPH;NIckalusKhan,BS;MarkVanPoppel,MD;MichaelMuhlbauer,MD(Memphis,TN)INTRODUCTION: Recentliteratureshows,imageguidanceforcerebrospinalfluidshuntingleadstomoreaccurateplacementoftheproximalcatheter.AccurateventricularcatheterplacementisusuallynotverifieduntilapostoperativeCTisperformed.Weanalyzethefeasibility,limitations,andaccuracyofusingtheMedtronicO-Armtoverifyplacementofthecatheterintheventricleintraoperatively.METHODS: Weevaluated5pediatricpatients,includingbothnewshuntplacementandrevisions.TheMedtronicO-Armwasusedtoverifyaccurateplacementoftheventricularcatheter.In2casesframelessneuronavigationwasusedtoguidepositioningandin3casesanatomiclandmarkswereutilized.All5patientsunderwentevaluationofventricularplacementusingtheO-arm.RESULTS: Fivepatients(ages3month-12yr)underwentintraoperativeimagingwiththeO-armtoattemptconfirmationofaccuratecatheterplacement.Etiologybeingpost-traumaticfor2patients,posttumorresection,pseudotumorandaquaductalstenosis.3ofthe5wereeasilyinterpretedshowingverificationofthecatheterintheventricle.The2casesinwhichintraoperativecatheterplacementfailedwassecondarytoartifactrelatedtoheadimmobilizationandoperatingroomequipment.CONCLUSIONS: TheO-Armhasbeenusedinthepediatricoperatingroomforprimarilyspineinstrumentation.ThecranialsoftwarethatwasdevelopedwillnowallowtheO-Armtobeusedinamultitudeofcranialcases.Multiplelessonswerelearnedandwillbeappliedgoingforwardtoimprovethisnewtechnology.ThisstudyshowsthefeasibilityofintraoperativeconfirmationofventricularcatheterplacementusingtheMedtronicO-arm.
150. INTRAVENTRICULAR HEMORRHAGE AND VENTRICULOPERITONEAL SHUNT REVISION: A RETROSPECTIVE REVIEWMarkCalayag,MD;AlexandraPaul,MD;MatthewAdamo,MD(Albany,NY)INTRODUCTION: Intraventricularhemorrhage(IVH)afterrevisingaproximalventriculoperitonealshunt(VPS)catheterisaknowncomplication,howeverthereissparseliteraturedescribingthehemorrhageandre-revisionrates.WeretrospectivelyreviewedourproximalVPSrevisionstodetermineourratesofIVHandearlyrevision.METHODS: ThemedicalrecordsofourpediatricpatientswhounderwentarevisionoftheirVPSfrom2009to2012werereviewed.Weincludedpatientswith:1)proximalcatheterrevisionsand2)post-operativeimagingwithinthreedays.Thisidentified52patients.Thedifficultyofremovingthecatheter,IVHonimaging,andre-revisionwithinonemonthwererecorded.AStudent’st-testwasperformedforstatisticalanalysis.RESULTS: Twenty-fivepercentofpatientshadevidenceofIVH,withtwopercenthavinganIVHgreaterthan5mlFifteenpercentofpatientswithIVHrequiredarevisionwithinonemonth,comparedtoeighteenpercentthatunderwentarevisionwithoutapriorIVH,howeverthiswasnotsignificant.Difficultyremovingthecatheterwassignificantlyassociated(p<0.01)withanincreaseinIVH(62%).Thepercentageofpatientswhounderwentrevisionaftertheremovalofadifficultcatheterwaslessthanthosethatwerefelttoberoutine(8%vs.59%).CONCLUSIONS: RemovalofaproximalVPScathetercarriesariskofIVH,butthismaynotbeclinicallysignificantintermsofneedinganearlyrevision.Thismaybetakenintoconsiderationwhendecidingtoremoveanexistingcatheterorjustplacinganewcatheter.
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151. ISOLATED CERVICAL SPINAL CANAL STENOSIS AT LEVEL OF THE ATLAS IN CHILDRENSohumK.Desai,MD;SudhakarVadivelu,DO;AkashPatel,MD;AndrewJea,MD(Galveston,TX)INTRODUCTION: Isolatedcervicalcanalstenosisattheleveloftheatlas,orC-1,isararecauseofcervicalmyelopathy.Ithasbeendocumentedinspondyloepiphysealdysplasiacongenita,Downsyndrome,andKlippel-Feil.Thepurposeofthisstudywastohighlightourexperiencewith4additionalpediatriccases,reviewtheliterature,andreportapreviouslyundocumentedassociationwithWilliamssyndrome.METHODS: ThemedicalrecordsandradiologicimagingstudiesoffourpatientstreatedatTexasChildren’sHospitalforsymptomatichypoplasiaoftheatlaswasretrospectivelyreviewed.Pertinentpatientdemographics,clinicalpresentation,imagingfindings,andoutcomesaftersurgerywererecorded.RESULTS: Ofthechildreninourseries,therewere4males.Theaverageageinourpediatricserieswas5.27years(range,13months-13years).Meansagittaldiameterofthespinalcanalattheleveloftheatlaswas9.88mm(range,8.3-11.4mm).TwopatientswithhypoplasiaoftheatlaswereassociatedwithWilliamssyndromewhichhasnotbeenpreviouslydescribed.Patientswerefollowedforanaverage7months(range,2weeks-15months)andnoneexperienceanypost-operativecomplications.LaminectomyofC1providedneurologicalimprovementinallpatientspresented.CONCLUSIONS: Congenitalhypoplasiaoftheatlasisararecauseofcervicalmyelopathy.Wehopethatthisreportwillpromptthecliniciantoconsideritwhensearchingforanetiologyforsignsandsymptomsofcervicalmyelopathy,especiallyinchildren.
152. LEPTOMENINGEAL ENHANCEMENT AS A DIAGNOSTIC AND PROGNOSTIC INDICATOR IN ATYPICAL TERATOID/RHABDOID TUMORIraEugeneBowen;YasserJeelani,MD;StephanieDaSilva,BA;J.GordonMcComb,MD;MarkKrieger,MD(LosAngeles,CA)INTRODUCTION: AtypicalTeratoidRhabdoidTumors(AT/RT)arearareprimaryCNStumorofchildhood.Althoughtheycanbeindistinguishablefrommedulloblastomasonimaging,AT/RTstendtohaveapoorerprognosis.METHODS: ThisIRB-approvedstudyretrospectivelyreviewed24childrenwithAT/RTbetween2000and2012.Theaverageageatdiagnosiswas4.8years;11/24(46%)werefemale.PreandpostoperativeMRIswereevaulatedfortumorsizeandlocation,leptomeningealenhancement,extentofresection,andpresenceofcalcification,cysts,hemorrhage,andnecrosis.Resultswerecomparedwith83agematchedpatientswithmedulloblastoma.MagneticResonanceSpectroscopywasavailablefor9oftheAT/RTpatients.RESULTS: Meanoverallfollow-upforthegroupwas38months(23monthsforAT/RTand42monthsformedulloblastoma).Theaverageoverallsurvival(OS)forAT/RTpatientswas21.7monthsvs.41monthsformedulloblastomapatients(p=0.03).TheOSformaleswithAT/RTwas17monthsvs39monthsforfemales(p=.05).8of24(33%)AT/RTspresentedwithleptomeningealenhancementvs8of83(9%)inmedulloblastomas.NosignificantdifferencewasseenintheOSinAT/RTpatientspresentingwithleptomeningealenhancementvsthosewithout,25and26monthsrespectively.At23monthsthemortalityforAT/RTswas13/24(54%).CONCLUSIONS: AT/RTsaremorelikelytohaveleptomeningealenhancementatpresentationcomparedwithmedulloblastoma.Asexpected,prognosisforAT/RTwasstatisticallyworsethanformedulloblastoma.WhileleptomeningealenhancementwasmorelikelytooccurinAT/RTitdidnotproveindicativeofapoorerprognosis.
153. LOW MORBIDITY OF MR-GUIDED LASER THERMOABLATION FOR HYPOTHALAMIC HAMARTOMADanielJ.Curry,MD;JeromeBoatey,MD;SudhakarVadivelu,DO;ThomasLuerssen,MD;RobertDauser,MD;AndrewJea,MD;RobertBollo,MD;AngusWilfong,MD(Houston,TX)INTRODUCTION: HypothalamicHamartomasarerestsofectopicneuronsthatcausegelasticepilepsyinchildrenandadults.Theepilepticsyndromesarehighlyresistanttomedicaltherapyrequiringsurgicalinterventionastheonlychanceforcure;manytechniquesforsurgicalinterventionhavebeendevelopedwithdifferentbalancesofefficacyandmorbidity.MR-GuidedLaserinterstitialThermalTherapyanewminimallyinvasiveapproachtothetreatmentofdrug-resistantgelasticepilepsy.Morbidityofthefirstseriesofcasesisreported.METHODS: EightpatientswithintractablegelasticepilepsyrelatedtoahypothalamichamartomaunderwentMgLITTofthelesion.Chartsofthepatientswerereviewedforevidenceofmorbidity.Specialattentionwasgiventohemorrhagiccomplications,infections,memorydisturbance,visualchanges,hormonalcomplications,affectchanges,andchangesinconsciousness.RESULTS: AlleightpatientsunderwentMRgLITToftheirHH.Thereareallfreeofgelasticseizuresaftertheablation.Therewasoneasymptomaticsubarachnoidhemorrhageatthetract.Threepatientscomplainedofnon-specificnon-disablinglethargy.Therewerenoincidencesofdiabetesinsipidus.Onepatienthadaprolongedstateoflethargywithanidiopathicreactiontoivphenytoin.Onepatienthadpost-opmemorydeficitthatresolvedwithsteroids.CONCLUSIONS: MR-GuidedLaserThermoablationofHypothalamicHamartomaisasafeandeffectivealternativetoopenresectionwithouttheneedforionizingradiationinyoungpatients.
154. MANAGEMENT OF RUPTURED DISSECTING INTRACRANIAL ANEURYSMS IN INFANTS: REPORT OF 4 CASES AND REVIEW OF THE LITERATUREAndrewJea,MD;VikasY.Rao,MD;RobertBollo,MD;WilliamWhitehead,MD;DanielCurry,MD;RobertDauser,MD;ThomasLuerssen,MD(Houston,TX)INTRODUCTION: Ruptureddissectingintracranialaneurysmsinthepediatricpopulationareinfrequentandthoseoccurringininfantslessthan1yearoldareextremelyrare.Wereviewourexperiencewithrupturedspontaneousintracranialdissectinganeurysmsininfantslessthan1yearold.METHODS: AretrospectivereviewofourpatientdatabasefromMid-2007toMid-2012withrupturedaneurysmswasperformed.Ofthesecases,infants1yearoldorlesswithimagingconsistentwithanintracranialdissectionwereidentified.RESULTS: Duringthestudyperiod,4infants1yearoldorlessweretreatedforruptureddistaldissectingintracranialaneurysmsatTexasChildren’Hospital.Inallcases,mycoticaneurysmsandcollagenvasculardisorderwereexcluded.Allpatientsinourseriespresentedwithsubarachnoidhemorrhageand3ofthe4hadintraventricularhemorrhageaswell.Allpatientsinthisseriesweremanagedintheacuteorsubacuteperiodwithsurgical(1patient)orendovascular(3patients)trappingwithoutdistalbypassprocedures.Thepatientstoleratedsacrificeoftheparentvesselsfeedingthesedistalaneurysmswellandallhavemadeexcellentfunctionalrecoveries.CONCLUSIONS: Basedonareviewofoursmallcaseseries,wefindthatintracranialdissectinganeurysmspresentingwithhemorrhagehaveanoverallgoodprognosis.Werecommendtreatingthispathologyininfantsaggressivelywitheithersurgicalorendovasculartrapping.Infantsmaytoleratesacrificeoftheparentarterywell,withouttheneedforabypassprocedure.Thisislikelyduetotheirrobustcollateralcirculation,andtheirexquisiteplasticityandcapacitytorecoverfromneurologicalinjuryatthisage.
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155. MESIAL TEMPORAL PARAMETERS INFLUENCING THE EXTENT OF THERMOABLATIONDanielJ.Curry,MD;SudhakarVadivelu,DO;AngusWilfong,MD(Houston,TX)INTRODUCTION: MR-GuidedLaserinterstitialThermalTherapy(MRgLITT)isanewminimallyinvasiveapproachtothetreatmentofintractableepilepsyinchildren.Preliminaryevidencehasshownthattheshapeofthelesionisheavilydependentuponlocaltissuethermodynamics,withcisternalandventricularsurfacesdissipatingthermalenergyandreducingtissueablation.Themedialcurvatureofthemesialtemporalstructuresaroundtheambientandcruralcisternspresentsaparticularchallengetoamygdalohippocampalablationthroughasingleoccipitotemporalpasswitha20mmmaximalablationdiameter.Wemeasuredthemaximummedialextentofmesialtemporallobefromtwopossibleablationtrajectoriesinaseriesofchildrenwithepilepsy.METHODS: Fiftypatients,aged8moto19years,withintractableepilepsyunderwentroutineT2weightedMRIofthebrain.Ataponto-mesencephalicaxialslice,twooccipitotemporalablationtrajectoriesweredrawn,oneimmediatelylateraltothechoroidalpoint,andanotherangledtrajectorythroughcenteroftheheadofthehippocampus.Thedistancefromthecisterntothetrajectorywasrecorded.RESULTS: Inthemedialablationvector,18%ofthepatientshadmedialtissuebeyondthemaximalablationdiameter,whereasinthelateralapproach61%haduncusbeyondtheradiusofablation.Inaddition,therewassignificantvariabilityinthemedialextentofuncusaftertheageof9years.CONCLUSIONS: MR-GuidedLaserThermoablationofthemesialtemporallobemaybemorecompletefromamedialtrajectory.Inpatientswherethemedialuncusismorethat10mmfromtheablationtrajectory,andtranstemporalablationshouldbeconsidered
156. MOYAMOYA DISEASE WITH MESIAL TEMPORAL SCLEROSIS: CASE REPORTSubashLohani,MD;JosephMadsen,MD;AnnBergin,MD;EdwardSmith,MD(Boston,MA)INTRODUCTION: Moyamoyaisacerebrovascularconditionthatpredisposesaffectedpatientstostrokeinassociationwithprogressivestenosisoftheintracranialinternalcarotidarteriesandtheirproximalbranches.Todateweareunawareofreportslinkingmoyamoyawithmesialtemporalsclerosis(MTS).METHODS: WeretrospectivelyreviewedthechartofapatientwhounderwentasinglestageoperationformoyamoyaandMTS.RESULTS: Thisfiveyearoldpatientstartedhavingseizuresatthreemonths.Initialevaluationrevealedarighttemporalarachnoidcyst,rightmedialtemporalcorticaldysplasiaandrightMTS.Seizurewascontrolledonmedications.Atage5,hebegantomanifestnewsymptomssuggestiveofTIA.Imagingrevealedright-sidedarteriopathyconsistentwithmoyamoya.Itwasdecidedthatrevascularizationwasneededforprogressivemoyamoya.DebatecenteredoverthelikelihoodofneedingsurgicaltreatmentforMTSlaterinlife.Giventhedifficultyinperformingalobectomyinthesettingofestablishedcollateralvessels,asinglestageoperationwasplanned.Thesequencewas:(i)dissectionoftheSTA,(ii)frontotemporalcraniotomy(iii)mesialtemporallobectomy(withintraoperativecorticographyandfenestrationofthecyst),(iv)pailsynangiosis.Post-operativecoursewasuneventful.Hehadnofurtherseizuresorstrokeand6monthpostoperativeMRIrevealedexcellentcollateralswithreversalofthepreviousivysign.CONCLUSIONS: Thiscasedemonstratestheco-existenceofMTSandmoyamoya.Thefindingofdualintracranialpathologyinmoyamoyamandatescarefulconsiderationofpotentialfuturesurgicalneeds.Resectionofanintraparenchymallesioncanbeperformedsuccessfullywithapialsyangiosisunderasingleanesthetic.
157. MOYAMOYA DISEASE: TWO DIFFERENT TECHNIQUES IN THE SAME PATIENT - CASE REPORT AND SURGICAL CONSIDERATIONSAlexandreCasagrandeCanheu,MD(Cianorte,Brazil)INTRODUCTION: Moyamoyadiseaseisdescribedashypoplasiaofbilateralinternalcarotidarteries.Thetreatmentisclinicalmedicaldevices,encephalo-duro-arterio-myo-synangiosis,arterialshuntsormultipleburr-holetoimprovethebrainvascularization.CaseReport:A6yearoldboypresentedrighthemiparesiswithmotorafasia.Imagingstudiesshowedclassicalfeaturesofmoyamoyadiseaseattheleftside.Hehadbeenoperatedontwoyearsagoinanotherhospitalbecausehehadpresentedlefthemiparesisanddrowsiness.Theimageshadshowedhipodenseimageinrightfrontallobeandocclusionofrightmiddlecerebralartery,besidesignsofbilateralmoyamoyadisease.Ithasbeenperformedencephalo-duro-arterio-myo-synangiosisattherightside.METHODS: Atthesurgeryafterexposureoftemporalmuscleandpericranium,severaltriangularshapesincisionsweremadeinthepericraniumallowingone-inchburrholejustbeneathofeachincision.Theduramaterandarachnoidwereopenedundermagnificationtoexposethepialvessels.Finallyweslippedeachleafofpericraniumintotherespectiveburr-holeallowingthecontactbetweenpialvesselsandpericranium.We’vedoneeightburr-holescoveringtheentireleftskullconvexity.RESULTS: Thepatienthasbeenfollowedupfor36monthsshowingnosymptomofmotororlanguagedysfunction.Thecerebralangiographyshowsbetterpialanastomosisattheleftsideaswellasmoreintensearterialirrigation.CONCLUSIONS: Surgicaltreatmentoffersthebestresultsandbenefitsformoyamoyadisease,butnostandardsurgicaltreatmentisestablished.Atleastforthiscase,multipleburr-holestechniccouldimprovebrainvascularizationbetterthanencephalo-duro-arterio-myo-sinangiosis.
158. NON-OPERATIVE CLINICAL OUTCOMES IN CHIARI I MALFORMATION PEDIATRIC PATIENTSAmyKilleen;AlexisChavez;MarkHenry;CarlHeilman,MD;StevenHwang,MD(Boston,MA)INTRODUCTION: Whilepost-operativeoutcomesofpediatricChiariImalformationpatientshavebeenwell-reported,thereisapaucityofliteratureconcerningnon-operativemanagementinthesepatients.WeconductedananalysisofclinicaloutcomesinChiariIpatientstreatedconservatively.METHODS: Weretrospectivelyidentifiedpediatricpatients(age≤18years)withadiagnosisofChiariImalformationwhowerenotrecommendedforsurgerybasedonlackofclinicalobjectivefindingsorlackofconsistentcoughheadaches.Weanalyzedclinicaldataandfollowedupwithpatientsviaphonesurvey.RESULTS: Of19patients(meanage:13.2+/-3.2years,followup:160.9+/-101.2months),10wereasymptomaticwhendiagnosedwithaChiariImalformation,presentingwithtrauma,seizures,headtilt,scoliosis,irritabilityanddevelopmentaldelay.Oneasymptomaticpatientlaterdevelopedmigraines.Twopatientspresentedwithcoughheadaches(onetussiveandonewhosebehavioralsymptomssuggestedcoughheadaches).Bothpatientshadresolutionoftheirsymptoms.3patientshadtheirnon-specificheadachesresolvewhile2patientssawimprovementintheseheadaches(onewasprescribedgabapentin).2patientshadtheirparasthesiasandemesisresolvewhilethe4patientswithsyrinxesdidnotdevelopanynewsymptoms.CONCLUSIONS: Inourstudy,wefoundthatallsymptomsofpediatricpatientseitherimprovedorresolvedovertime.Althoughwearelimitedbyasmallseries,thiscorroboratestheimportanceofpatientselectionasacriticalfactorindecidingwhobenefitsfromsurgicalinterventionandcanhelpassurefamiliesthatsymptomswilllikelyimprove.
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159. WITHDRAWN
160. PATENT FORAMEN OVALE AND CONGENITAL CRANIOSYNOSTOSIS: MANAGEMENT CONSIDERATIONS AND ASSOCIATED RISKSSamerK.Elbabaa,MD,FAANS;SaadehAl-Jureidini,MD;AlexanderLin,MD(St.Louis,MO)INTRODUCTION: Patentforamenovale(PFO)isacardiacanomalythatcanpotentiallyallowembolitotravelfromvenoustoarterialcirculation,whichcouldleadtocoronaryinfarctionorstroke.Incongenitalcraniosynostosis,surgicalrepairhastheriskofairembolism.Whenbothconditionscoincide,themanagementisunclear.BothearlyPFOrepairanddelayedcraniosynostosisrepaircarrytheirownuniquerisks.WepresenttwopatientswithbothcraniosynostosisandPFOtodiscusspotentialmanagementoptionsandoutcomes.METHODS: InclusioncriteriawerepatientswithcraniosynostosisandPFOtreatedwithamultidisciplinaryapproachwhichincludesapediatricneurosurgeon,pediatriccraniofacialplasticsurgeonandaninterventionalpediatriccardiologist.RESULTS: PatientA.2-year-oldwithJacobsensyndromeincludingmetopiccraniosynostosis,Paris-TrousseauplateletdisorderandcardiacanomaliesincludingPFO.HereceivedpercutaneousPFOocclusionseveralmonthspriortocraniosynostosisrepair.Noneurologicnorcardiaccomplicationsafterbothprocedurescompleted.PatientB.9-month-oldwithmetopiccraniosynostosisandPFOwhosecardiacanatomydidnotallowearlypatching.Instead,PFOwastemporarilyoccludedwithballooncatheterizationduringasimultaneouscraniofacialcorrectionsurgeryinthehybridoperatingsuite.Duringearlypostoperativeperiod,patientwasnoticedtohaveamildrightarmweakness.CTandMRIscansconfirmedasmallacuteinfarctneartheleftinternalcapsule.Echocardiographydemonstratednoongoingthrombogenicetiologies.Radiographicallyandclinically,theinfantrecoveredverywell.CONCLUSIONS: PatientswithsimultaneouscraniosynostosisandPFOareuniqueandcomplex,requiringanindividualizedapproachfromamultidisciplinaryteamtobestinformtheparentsoftherisksandbenefitsofintervention.DifferentmanagementconsiderationsincludeearlypercutaneousendovascularrepairorsimultaneoustemporaryballoonocclusionofPFOduringcraniofacialcorrection.
161. PATTERNS OF CARE FOR CRANIOPHARYNGIOMA: SURVEY OF AANS MEMBERSHIPCesarAugustoSerranoAlmeida,MD;SarahWilliams;NicholasPalmeri,BA;MichelleTorok,PhD;MichaelHandler,MD;ArthurLiu,MD,PhD;ToddHankinson,MD(Aurora,CO)INTRODUCTION: Initialtherapyforcraniopharyngiomaremainscontroversial.Recentanalysesindicatethattraditionalalgorithms(grosstotalresectionversussubtotalresectionwithradiation)arenotemployedinmanycases.Weendeavoredtoverifythesefindingsandinvestigateneurosurgicalpracticepatternsforpatientswithcraniopharyngioma.METHODS: Aninequestionsurveywasdesignedandelectronicallydistributedto2974AANSmembersasanAANSSpecialAnnouncement.ResponseswerecollectedthroughZoomerangandanalyzedusingstandardstatisticaltechniques.RESULTS: Onehundredtworesponseswerecollected(3.43%responserate).36%ofrespondentsestimatedtheirpracticetoinclude<75%pediatricpatientsand61%describedtheirpracticeasacademic.36%ofrespondentsindicatedthat,undercertaincircumstances,theywouldrecommendobservationorradiationtherapyforasuspectedcraniopharyngiomaintheabsenceofatissuediagnosis,with46%oftheseindicatingthisrecommendationin<10%ofcases.FollowingGTR,90%ofrespondentsneverrecommendadjuvantRT.FollowingSTR,35%alwaysrecommendRTand59%recommenditinoverhalfofcases.However,followingSTRortissuebiopsyalone,18%and11%,respectively,neverrecommendXRT.Therewasnocorrelationbetweenrespondent’stypeofpractice(i.e.academicor<75%pediatrics)andpracticepatterns.CONCLUSIONS: Althoughconclusionsarelimitedbyalowresponserate,aconsiderablesubsetofpatientswithcraniopharyngiomaarenottreatedwiththealgorithmsthataremostcommonlydescribedintheacademicliterature.Furtherinvestigationregardingthepresentationandoutcomesofthesepatientsmayhelpshapefuturetherapies.
162. PEDIATRIC BRAIN TUMORS AND HYDROCEPHALUSRabiaQaiser,MD;DavidLancton,BS;DanielGuillaume,MD(Minneapolis,MN)INTRODUCTION: Hydrocephalusiscommoninchildrenwithbraintumorsandcanbesecondarytodirectobstructionbythetumor,and/orsecondarychangesthatcaninterferewithcerebrospinalfluidclearance.Inthisstudy,theauthorsaimedtodeterminethepercentageofchildrenwithbraintumorswhohavehydrocephalusandtheoddsofhavinghydrocephalusbasedontumorlocation.METHODS: Aretrospectivecohortwascreatedusingthe2009Kids’InpatientDatabasetoidentifychildrenyoungerthan21yearsofagewithbraintumors,hydrocephalusorboth.HydrocephalusandbraintumorwasascertainedbyICD-9diagnosiscodes.DatawasretrievedandoddsratiowascalculatedusingSAS(StatisticalAnalysisSoftware).RESULTS: Inthissample,2,634childrenhadaprimarydiagnosisofanybraintumor(Cerebrum:202;Frontal:208;Temporal:208;Parietal:108;Occipital:51;Ventricle:270;Cerebellum:500;BrainStem:315;Other:772).Ofthechildrenwithtumors,963(36.6%)hadasecondarydiagnosisofhydrocephalus(23communicating,933obstructive,7congenital).Theproportionwithassociatedhydrocephalusvariedbetweenbraintumorlocationswiththelowestbeingtemporal(4.8%)andthehighestbeingbrainstem(36.5%),cerebellum(42.0%)andventricular(61.1%).Theoddsofhavinghydrocephaluswithaninfratentorialtumor(odds=0.66)was6.15timeshigherthanforsupratentorialtumors(odds=0.11).CONCLUSIONS: Hydrocephaluswasasecondarydiagnosisin36.6%ofallpatientswithbraintumorsespeciallywithventricularandposteriorfossatumors.Furtherstudieswillidentifyassociationswithhistology,andhydrocephalustreatment(shuntingversusendoscopicthirdventriculostomy).
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163. PEDIATRIC SKULL BASE CHORDOMAS: SURGICAL RESULTS AFTER ENDOSCOPIC ENDONASAL SURGERYElizabethTyler-Kabara,MD,PhD;MariaKoutourousiou,MD;PaulGardner,MD;StephanieHenry;CarlSnyderman,MD(Pittsburgh,PA)INTRODUCTION: Pediatricskullbasechordomasareaggressivetumorsusuallyrequiringmultimodalitytreatment.METHODS: Weretrospectivelyreviewedthemedicalfilesof10pediatricpatients(age:4-8years,80%male)whounderwentendoscopicendonasalsurgery(EES)forclivalchordomas.RESULTS: Clinicalpresentationincludedcranialnervepalsies(60%)andheadache(40%),while2patientswereasymptomatic.TheyallunderwentEES,combinedwithopenapproaches(farlateralortranscervical)in4cases.Threepatientsunderwenttwo-stageapproachesandonerequired7surgeries(5EESand2farlateralcraniotomies).Grosstotalresectionwasachievedin70%,neartotal(<95%)in20%andsubtotal(<85%)in10%.Tworequiredoccipito-cervicalfusionpostoperatively.Presentingsymptomatologywasimprovedorresolvedineverycase.Surgicalcomplicationsincludedcerebrospinalfluidleakin2patientstreatedwithsurgicalexplorationandlumbardrainplacement,andcarotidlacerationinonecaserequiringcarotidocclusion,resultinginaHorner’ssyndromewithoutfurthercomplications.Aspartoftheinitialtreatment,7patients(70%)receivedadjuvantradiotherapyaftersurgery(protonbeamin6cases,conventionalradiotherapyinone).Withameanfollow-upperiodof32months(2-68months),6patientsremainfreeofdiseaseand4showedrecurrence:onewithaggressivedeteriorationreceivedchemotherapybutdiedwithin5months,2withminimalrecurrenceareinclosefollow-upandonewasre-operatedtwiceformultiplerecurrences.CONCLUSIONS: EESrepresentsasafeandfeasiblesurgicaltechniqueforthetreatmentofpediatricskullbasechordomaswithresultscomparableifnotevenbetterthanopenapproaches.
164. POSTERIOR LUMBAR INTERBODY FUSION IN CHILDRENJulianJ.Lin,MD;AhmadIssawi,MD;AlexHass,BS(Peoria,IL)INTRODUCTION: Spondylolysisinchildrenisuncommon;surgeryisindicatedforslipprogression,high-gradeslipwithsagittalimbalance,neurologicdeficit,andpainunresponsivetoprolongedconservativetreatment.METHODS: Retrospectivecaseseriesof7pediatricpatientsundergoingtreatmentwithtransforaminallumbarinterbodyfusion(TLIF)andmodifiedSpeedprocedure.RESULTS: AllpatientshadfailedconservativemanagementandsubsequentlysixunderwentL5-S1TLIF,oneL4-5TLIF,andonemodifiedL4-S1Speedprocedure.Averageagewas14.6.Maletofemaleratiowas1:1.Averagefollowupperiodwas15months.FivepatientswithlowgradelishtesisunderwentL5-S1TLIF,oneunderwentL4-L5TLIF.Ofthemonepatienthadapostopinfectionandonelaterdevelopedspondylolysisatahigherlevel.Onepatientwithgrade3listhesiswokeupwithpostopweaknesswhichimprovedafterrelaxationofthereduction.Onepatientwithgrade5spondylolisthesisunderwentthemodifiedSpeedprocedure.Allpatientshadimprovementorresolutionoftheirsymptomsonfollowup.CONCLUSIONS: TheresultsofourcaseseriessuggestthatTLIFproceduresforspondylolisthesisprovideadequateresolutionofsymptomswithlowriskofcomplication.Patientswithhigher-gradespondylolisthesisundergoingTLIFmayhavegreaterriskforcomplications.
165. PRACTICE TRENDS IN THE UTILIZATION OF INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING IN PEDIATRIC NEUROSURGERYSudhakarVadivelu,DO;SatishAgadi,MD;RobertSchmidt;PrasithaMani;AkashPatel,MD;SohumDesai,MD;SabihEffendi,MD;ChristopherGlover,MD;ThomasLuerssen,MD;AndrewJea,MD(Houston,TX)INTRODUCTION: TheDecadeoftheBraininthe1990sintroducedhigherbenchmarksinsafetyforpatients,adultandpediatric,undergoingneurosurgery.Weidentifiedcurrenttrendsintheutilizationofintra-operativeneuro-monitoring(IONM)asanadjuncttoneurosurgeryinourpracticeattheDivisionofPediatricNeurosurgeryatTexasChildren’sHospital.METHODS: Atotalof4,467neurosurgicalprocedureswereperformedin2,352pediatricpatientsfrom2008-2011.Aretrospectivechartreviewexaminingsurgeon,procedure,patientcharacteristics,andpre-operativecomplicationswererecordedbasedonwhetherIONMwasusedornot.RESULTS: Duringthe4-yearperiod,thepercentofneurosurgicalproceduresperformedwithIONMincreasedapproximately12%toahighof34%.Surgeon-relatedfactorswhereIONMwasmorelikelyusedincludedsurgeons<10yearsinpractice,procedure-relatedfactorsincludedposteriorspinalfusions,andpatient-relatedfactorsincludedchildrenolderthan3yearsofageandwithoneormorecomorbidities.TheneurologicalcomplicationrateofcasesperformedwithIONMrangedfrom2.4-6.9%,averaging4.7%islowcomparedtocaseswithoutIONM(rangefrom3.1-10.1%,averageof7.23%).CONCLUSIONS: Substantialtrendswereobservedinourpractice.ThepercentofproceduresperformedwithIONMincreasedduringthe4-yearperiod.YoungersurgeonswithsubspecialtyinterestperformedspineorposteriorfossasurgeriesinolderchildrenwithsignificantcomorbiditiesweremostlikelytouseIONM.ThisisthefirststudytoexaminepracticetrendsintheuseofIONMinpediatricneurosurgery.
166. PREDICTING INCIDENCE OF CSF DIVERSION PROCEDURES IN PEDIATRIC PATIENTS WITH POSTERIOR FOSSA TUMORSLilianaC.Goumnerova,MD,FAANS,FACS;SarahJernigan,MD,MPH(Boston,MA)INTRODUCTION: Hydrocephalusisassociatedwithposteriorfossatumors.Therearevariableratesreportedforshunting.Wereviewedour10yeardataandPHISdataforthesametimeperiodtodefineratesofshunting,practicepatternsandinstitutionalindicationsforshunting.METHODS: WeperformedaretrospectivereviewofallpatientswiththediagnosisofposteriorfossatumorstreatedatourinstitutionandfromthePHISdatabaseutilizingICD9andCPTcodes.SASwasutilizedforstatisticalanalysis.Patientswhohadundergoneprimarysurgicalresectionelsewherewerenotincluded.RESULTS: Weidentified141patientsfrom2006until2010,inclusive,whounderwentsurgeryforposteriorfossatumors.13of141(9.2%)underwentinsertionofaVPshuntafterresectionoftheirtumor,noneofthemunderwentETVs.3ofthesepatientswerehighriskaccordingtotheCPPRHcriteriaandtheremaining10werelowrisk.12of13hadmoderatetoseverehydrocephalus.However,moderatetoseverehydrocephaluswaspresentin54patients(38.3%)andonly22.2%requiredshunting.CPPRHscorewascalculatedforallpatientsandonly3ofourshuntedpatientswereinthehighriskgroup.10of128(7.8%)werehighriskbutdidnotrequireaCSFdiversionprocedure.ThePHISdatawillalsobepresentedtoprovidenationalpracticepatterninformation.CONCLUSIONS: OurinstitutionalrateforCSFdiversionwassubstantiallylowerthanthatreportedinotherlargecaseseries.TheCPPRHscoredidnotcorrelatewithshuntingandthismayreflectdifferenceinpracticepatterns.
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167. PRIMARY GLIOBLASTOMA OF THE CEREBELLUM IN CHILDREN: REPORT OF 5 CASES AND REVIEW OF THE LITERATUREAndrewJea,MD;GaddumReddy,MD,PhD;AnishSen,MD;AkashPatel,MD;RobertBollo,MD(Houston,TX)INTRODUCTION: Primarycerebellarglioblastomas(GBM)inchildrenarerare.Asaresult,anoptimaltreatmentstrategyhasnotyetbeenidentified.Areviewofthecharacteristicsofthediseaseaswellastheeffectivenessofvarioustherapeuticmodalitieswouldhelpinoptimizingthetreatmentparadigm.METHODS: Weperformedadetailedclinical,radiographic,andpathologicretrospectivereviewoffivepatients(3boysand2girls;averageageatpresentation7.2years[range,3-14years]),andsurveyedtheliteratureforanadditional55cases.RESULTS: Computedtomographyandmagneticresonanceimagingusuallyrevealedalargelesionwithminimaledema,heterogenouscontrastenhancement,andadiscreteborder.Subtotaltumorresectionwasperformedintwopatients;grosstotalresectioninthreepatients.Immunostainingofthetumorcellswithantiseratoglialfibrillaryacidicproteinandvimentinwasvariablypositive.Adjuvanttherapyincludedlocalradiationandchemotherapyinallfollowedpatients.Tumorrecurrencewasseenintwopatients.Patientswerefollowedfrom2monthsto3.5years(mean,12months).Twopatientsweredeadatlastfollowupwithameansurvivalof9.5months.CONCLUSIONS: Theprognosisforpediatricpatientswithcerebellarglioblastomasisdismal,evenwhencomparedtoadultcounterpartsorothermalignantposteriorfossatumorsinchildren.Cerebellarglioblastomashaveatendencytorecurdisseminatedespitetreatmentwithsurgery,chemotherapyandradiation.Thepooroutcomesseenwiththistumorsuggeststhattheoptimaltreatmentstrategyhasyettobeelucidatedandmuchworkneedstobedone.
168. PROGNOSTIC FACTORS ASSOCIATED WITH SURVIVAL AND DECISION-MAKING IN PEDIATRIC CRANIAL GUNSHOT WOUNDSMichaelGeorgeDeCuypere,MD;KyleGabrick,BS;PaulKlimoJr.,MD,MPH;FrederickBoop,MD;MichaelMuhlbauer,MD(Cordova,TN)INTRODUCTION: Penetratingtraumaticbraininjury(TBI)islesscommonthanblunt,butmoresevere,withcranialgunshotwounds(GSW)beingassociatedwithhighmorbidityandmortality.Notunexpectedly,themajorityofliteratureonintracranialGSWfocusesonadultswithlittleonthemanagementandoutcomesinchildren.Thegoalofthisstudyistoidentifyclinicalandradiographicfactorspredictiveofoutcome.METHODS: AretrospectivereviewofisolatedGSWtotheheadwithintracranialinjuryfrombirthto18yearsattwomajormetropolitanLevel1traumacentersfrom1996-2012(N=65).Severalstandardclinicalandradiographicfactorswerereviewedandanalyzedforpredictivevalueinsurvivalandoveralloutcome.RESULTS: Overallmortalityreached48%,with62%ofsurvivorsachievingfavorableclinicaloutcome(GOS≥4).Sevenindependentfactorsforsurvivalwereidentified:initialICP<30mmHg,≥1reactivepupil,absenceofdeepnuclearinjury,singlehemisphericinvolvement,absenceoftransventriculartrajectory,<3lobeinjury,andabsenceofmidlineshift(P<0.05).Agewasnotassociatedwithsurvival.Additionally,lowhematocritandhighbasedeficitwereassociatedwithdeath(P<0.05).Thismayreflectlongertransittimetomedicalcareand/oracutehighintravascularvolumeloss.CONCLUSIONS: ThisseriesofpediatriccranialGSWsunderscorestheimportanceofinitialclinicalexam,imagingcharacteristics,andadequateresuscitationinclinicaldecision-making.Thefactorsidentifiedmaybeusefultothephysicianinmakingdecisionsandcounselingfamilies.
169. PROGNOSTIC ROLE FOR DIFFUSION-WEIGHTED IMAGING OF DIFFUSE INTRINSIC PONTINE GLIOMAMichaelEdwards,MD;RobertLober,MD,PhD;KristenYeom,MD;YujieTang,PhD;SoniaPartap,MD;Yoon-JaeCho,MD;PaulFisher,MD;TerriHaddix,MD;MichelleMonje,MD,PhD(Stanford,CA)INTRODUCTION: Weinvestigatedwhetherdiffusion-weightedimaginghelpspredicttheclinicalcoursefordiffuseintrinsicpontineglioma(DIPG).METHODS: WecomparedsurvivalbetweengroupsofDIPGpatientsstratifiedbasedontumorapparentdiffusioncoefficient(ADC).Correlativehistologywasavailableinthreepatients.RESULTS: Medianageatdiagnosiswas6.6(range2.3to13.2)years,withmedianfollow-upseven(rangeoneto20)months.Therewere14boysandsixgirls.Seventeenpatientsreceivedradiotherapy,fivereceivedchemotherapy,andsixunderwentCSFdiversion.ThemedianADCof1295x10-6mm2/sforthecohortpartitionedtumorsintoloworhighdiffusiongroups,whichhaddistinctmediansurvivalsofthreemonthsand13months,respectively(log-rankp=0.001).Lowdiffusiontumorswerefoundonlyinboys,whereashighdiffusiontumorswerefoundinbothboysandgirls.Atautopsy,twoavailablelowdiffusiontumorspecimensdemonstratedhighgrade(gradeIIItoIV)histology,whereastheoneavailablehighdiffusiontumordemonstratedlowgrade(gradeII)histology.Autopsydatafromonepatientdemonstratedametastaticperiventricularnodulewithhighergradehistologythanwhatwasfoundinpons,withcorrespondinglowerdiffusioninthelesiononimaging.CONCLUSIONS: Diffusion-weightedimagingmightbeusefulforpredictingtumorbehaviorandstratifyingpatientsinprospectivestudiesthatassesstreatmentresponse.
170. WITHDRAWN
171. REGIONAL WHITE MATTER CHANGES DETECTED BY DIFFUSION TENSOR IMAGING IN EXPERIMENTAL NEONATAL HYDROCEPHALUSJamesP.(Pat)McAllisterII,PhD;RaminEskandari,MD;OsamaAbdullah,MS;KelleyLloyd,MS;AngelaFreeman,BS;MelissaPacker,BS(SaltLakeCity,UT)INTRODUCTION: Diffusiontensorimaging(DTI)maybevaluableforassessingwhitematterdamageinvivoduringhydrocephalus,butcytopathologicalcorrelations,andthusknowledgeofpathophysiologicalmechanisms,arelacking.Weusedourwell-establishedexperimentalmodeltofurtherexplorethesecorrelations.METHODS: Hydrocephaluswasinducedintwoweek-oldfelinesbyintracisternalkaolininjections.Ventricularreservoirswereplacedone(early,n=6)ortwo(late,n=3)weekspost-kaolinandtappedbasedexclusivelyonneurologicaldeficits.Integrityoftheinternalcapsule(IC)andcorpuscallosum(CC)wasevaluatedbeforereservoirplacementandeverythreeweekswithDTIfractionalanisotropy(FA)andmeandiffusivity(MD).Brainsfromhydrocephalicandage-matchedcontrol(n=3)animalssacrificedat12weekspost-reservoirwereprocessedforimmunocytochemistry.RESULTS: InIC,FAandMDwereunchangedinearlyandlatehydrocephalicanimalscomparedtocontrolsbutastrocytosiswassignificantlyelevatedinearly(p=0.001)andlate(p=0.031)groups.Lateanimals,however,demonstratedsignificantlylowerastrocytosis(p=0.014)thanearlyanimals.TheCCdemonstratedappreciabledecreasesinFAandincreasesinMDinbothinearlyandlateanimalscomparedtocontrolsatthreeweekspost-reservoirplacement(p=0.004and0.055,respectively).CONCLUSIONS: HydrocephalicanimalstreatedwithintermittentventricularreservoirtappingusingclinicalcriteriaalonedemonstratedwhitematteralterationsthatweredetectablebyDTIandwerestructure-specific,i.e.theCCwasmuchmoreaffectedthantheIC.AstrogliosisintheIC,however,wasnotcoupledtoDTImeasurements,suggestingthatinsomewhitematterstructuresDTImaynotdetectimportantcytopathology.
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172. SAFETY OF CORPUS CALLOSOTOMY AND VAGAL NERVE STIMULATION IN PEDIATRIC EPILEPSYMarkDanielVanPoppel,MD;JamesWheless,MD;FrederickBoop,MD;StephanieEinhaus,MD;StephenFulton,MD;AmyMcGregor,MD;KatherineVanPoppel,MD;PaulKlimo,MD(Memphis,TN)INTRODUCTION: Vagalnervestimulation(VNS)andcorpuscallosotomy(CC)areeffectivepalliativeproceduresforreducingseizurefrequencyinrefractoryepilepsy.ItisassumedthatVNSplacementhasfewersurgicalcomplicationscomparedtoCC,whichinfluencesthedecisionforchoosingapalliativeprocedure.Weanalyzedalargemodernpediatricpopulationwithrefractoryepilepsycomparingthesafetyofbothprocedures.METHODS: AllcasesofVNSplacement,VNSrevisionorcorpuscallosotomyperformedbetween2005and2012werereviewedforsurgicalcomplications.Thecaseswereperformedatasinglepediatricinstitutionby3surgeons.RESULTS: 75patientsunderwentCCwithasurgicalcomplicationrateof6%.CCcomplicationsincluded1delayedhematoma,2infectedboneflaps,1pseudomeningocele,and1abortedprocedure.170patientsunderwentVNSplacementorrevisionwithasurgicalcomplicationrateof5%.VNScomplicationsincluded6infections,1vocalcordparalysis,and2sterileinflammatoryreactions.Nopatientineithergrouphadpermanentmorbidityormortality.FortypercentofpatientsundergoingCChadaVNSplacedprior,and10%percentofpatientshadconcurrentVNSplacementandCC.Lessthan1%ofpatientsunderwentCCpriortoundergoingVNSplacement.CONCLUSIONS: ManybelieveVNStherapyisasaferprocedurethanCC,howeverinthispediatricpopulationVNStherapycarriedequalsurgicalriskwithnopermanentdisabilityineithergroup.Intreatmentofrefractoryepilepsy,VNStherapywasconsiderablymorecommonthanCCdespitesimilarsurgicalrisks.
173. SECONDARY DISSEMINATION OF MEDULLOBLASTOMAS IN CHILDRENSaraGhayouri;YasserJeelani,MD;StephanieDaSilva,BA;J.GordonMcComb,MD;MarkKrieger,MD(Tallahassee,CA)INTRODUCTION: One-thirdofmedulloblastomasdisseminateoverthecourseofthedisease.Thesedisseminatedtumorscarryanextremelypoorprognosis;however,riskfactorsandpatternsofdisseminationhavebeenpoorlydescribedtodate.METHODS: UnderIRBapproval,aretrospectiveanalysiswasperformedonallpatientsatasingleinstitutionwithahistologicaldiagnosisofmedulloblastomaovera10yearperiodwithcompleteclinicalandradiographicfollow-up.Disseminationpatternswereanalyzed.RESULTS: Fifty-sevenpatients(33male)wereidentified.Themeanageatdiagnosiswas7.5years.Medianfollow-upwas3.7years.Allweretreatedunderstandardprotocols.Sixhaddisseminateddiseaseatpresentation;1wasunder3yearsofageand5wereolder.21haddisseminationduringtheirdiseasecourse;3wereunderage3and18wereolder.13/21(61%)ofchildrenwithsecondarydisseminationhadgrosstotalresectionoftheirtumorsinitially.Survivalaftersecondarydisseminationwasonaverage13.7months.Age,histology,location,andsizeoftumordidnotimpacttherateofsecondarydissemination.Secondarydisseminationdidnotindependentlyimpactsurvivalinyoungchildren,butwasassociatedwithaworseoutcomeinchildrenover3yearsofage(p=0.04).CONCLUSIONS: Secondarydisseminationofmedulloblastomasisrelativelycommon,andcanoccurevenwhenthereisgrosstotalresectionofthetumoronpresentation.Secondarydisseminationwasshowntoconveyaworseprognosisinstandardriskpatients(i.e.,olderchildren).
174. SHUNT INFECTIONS IN CHILDREN LESS THAN ONE YEAR OF AGEMeysamAliKebriaei,MD;StevenSalinas,BS;FalkenstromKristina;WilliamBoydston,MD,PhD;BarunBrahma,MD;AndrewReisner,MD;DavidWrubel,MD;JoshuaChern,MD,PhD(Atlanta,GA)INTRODUCTION: Childrenlessthanoneyearofageareuniqueintheirphysiologyandcomorbidities.Literaturesuggeststheriskforshuntinfectionmaybedifferentinthispopulationcomparedtothoseofanolderage.METHODS: Inthe3-yearperiodbetween2009to2011,284CSFshuntswereinsertedinchildrenlessthanoneyearofageatourinstitution.Clinicalcharacteristicsandshuntinfectionswereprospectivelyrecordedinthepracticeandhospitaldatabase.Multivariateanalysiswasutilizedtodelineateriskfactorsforshuntinfections.RESULTS: Thestudyincluded270patients.Averagegestationalagewas27.2weeks,andaveragebirthweightwas1065grams.Averageweightattimeofshuntinsertionwas4281grams.63patientshadaventricularaccessdevice(VAD)insertedpriortoshuntinsertion,37patientsunderwentmyelomeningoceleclosure,and72patientsunderwentotherinvasiveprocedures(definedasVADinsertion,shuntrevision,openorlaparoscopicG-tubeinsertion,openabdominalprocedures,andopencardiacprocedure)within30daysofshuntinsertion.Shuntinfectionoccurredin21patients(19withorganismisolatedand2withabdominalpseudocyst).Multivariateanalysisshowedinvasiveprocedurewithin30daystobetheonlyriskfactorthatpredisposedthepatienttoshuntinfection(O.R8.1,p=0.0024).CONCLUSIONS: Theresultsofthisstudysuggestthatinvasiveprocedurewithin30daysofshuntinsertionisassociatedwithahigherriskofshuntinfectioninchildrenwhoseshuntwasinsertedpriortooneyearofage.
175. SKULL BASE SURGERY IN PEDIATRIC PATIENTS: A SINGLE INSTITUTIONAL ANALYSIS OF 75 CASESTimothyRyanOwens;RanjithBabu,BS;TimothyMiller,MD;ReneeReynolds,MD;HerbertFuchs,MD;CarrieMuh,MD;TakanoriFukushima,MD;GeraldGrant,MD(Durham,NC)INTRODUCTION: Thegoalofthisstudyistoexaminetheapplicationofskullbasesurgicaltechniquesinapediatricpopulation.Theliteratureregardingsurgicalmanagementofpediatricskullbaselesionsisverylimited;therefore,weexaminedourinstitution’sexperience.METHODS: ThisisanIRBapprovedretrospectivereviewofaconsecutiveseriesofpatientsbelowtheageof18whounderwentaneurosurgeryprocedureusingaskullbaseapproachbetween01/01/2000and7/01/2012.ThecohortwasderivedusingDukeUniversity’sDEDUCEqueryingtoolandwasextractedbasedonCPTcodescorrespondingtotheskullbaseproceduresperformed.RESULTS: Seventy-fivecaseswereidentifiedwith41boysand34girls.Themeanagewas10.3yearsandmedianfollow-upwas22.2months(mean=48).Twenty-twotypesofintracranialpathologywererepresentedwithschwanommasandcraniopharyngiomabeingthemostcommon(32%).Themostcommonapproacheswereanterolateralandtransphenoidal.Grosstotalresectionwasachievedin58%ofcases.Fifty-twopercentofpathologieswerenotedtobeattachedtoadjacentneuralstructures.Complicationratewas56%overallandincludedtransientcranialnervedeficits,CSFleaks,infection,andonedeathwhichoccurredintheimmediatepost-operativeperiod.CONCLUSIONS: Pediatricskullbaselesionsarerareandthesurgicalapproachesarechallenging.Althoughgoodoutcomesoverallhavebeenreportedinthepediatricpopulation,furtherworkisongoingtoinvestigatefactorsthatcontributemosttoachievingagrosstotalresectionandminimizingpost-operativemorbidityinpatientswithpediatricskullbaselesions.
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176. SPINAL CORD INFARCTION FOLLOWING MINOR TRAUMA IN CHILDREN: FIBROCARTILAGINOUS EMBOLISM AS A PUTATIVE CAUSEMatthewFrankGary,MD;JoshuaChern,MD,PhD;DamienGrattan-Smith,MBBS;MesyamKebriaei,MD;AndrewReisner,MD(Atlanta,GA)INTRODUCTION: Spinalcordinfarctionfollowingseeminglyinnocuoustraumainchildrenarerare,devastatingevents.Wepresent3casesofpediatricspinalcordinfarctionthatfollowedminortrauma.Ananalysisoftheclinical,radiographicandlaboratoryfeaturesofthesecasessuggestthatembolismofthenucleuspalposusintothespinalcordmicrocirculationisthelikelymechanism.Areviewofhumanandveterinaryliteraturesupportsthisnotion.Thisisthelargestpediatricseriesofmyelopathysecondarytoembolismofthenucleuspalposusreportedtodate.METHODS: Thisisaretrospectivesingle-centerstudywhichreceivedIRBapproval.RESULTS: Threepatients,aged8months,8yearsand12yearsofage,presentedwithacutecervicalmyelopathyfollowingseeminglyinnocuoustrauma.Allpresentedwitha“spinalstrokeinevolution”.Afteravariablelatentperiod,theprogressionofthemyelopathywasrapidover24hours.Thedegreeofspinalcordinjurywassevere(ASIABorC).TheCSFresultsinallcaseswasnegativeforinfectious,inflammatoryordemyelinatinglesions.MRIfindingsincludedprogressivespinalcordenlargement,subjacentdiscdisease,increasedspinalcordT-2signalchanges,andnocontrastenhancement.Allpatientsweretreatedwithsteroids.Therewasahighincidenceofconcurrentinfections.TwopatientsrecoveredtoanASIAD,oneremainedanASIAC.CONCLUSIONS: Thepathophysiologyofspinalcordinfarctionfollowingminortraumaremainsenigmatic.Embolizationofdiscmaterialtothespinalmicrocirculationisaputativemechanismwithdistinctclinical,radiographicandlaboratoryfeaturesthatallowdifferentiationfromothercausesofacutemyelopathy.
177. SPINAL DYSRAPHISM: A CHALLENGE CONTINUED TO BE FACED BY NEUROSURGEONS IN DEVELOPING COUNTRIESAmitAgrawal,MD(Nellore,India)INTRODUCTION: Theincidenceofspinaldysraphismhassignificantlydecreasedoverthelastfewdecades,allovertheworld;however,stilltheincidenceinmuchhigherindevelopingcountrieswithpoorsocio-economicstatus.METHODS: Thepresentstudyincludesallthepatientsmanagedforspinaldysraphismoveraperiodofoneyear(January2011-December2011).Detailsofallthepatientsincludingdemographics,antenatalcarehistory,siteandtypeoflesion,neurologicalexamination,imagingfinding,associatedcongenitalanomalies,managementofferedandoutcomewererecorded.RESULTS: Atotal28childrenwereoperatedforspinaldysraphismduringthestudyperiod(17maleand11female).Meanagewas14days(agerange1dayto2190days,median120days).Mothersof15childrendidnotseekanyregularantenatalcheckupandonly13mothersreceivedfolicacidsupplementationduringpregnancy.14childrenweredeliveredathomeand14wereathospital.Themostcommonsitewaslumbo-sacralregion(67.8%).7patientshadruptureofthesacatthetimeofpresentation,1childhadlocalinfection,4patientshadhydrocephalus(requiredshuntbeforesurgicalrepair).Themeanhospitalstaywas7days(range5daysto31days,median10days).CONCLUSIONS: Spinaldysraphism,isstillamajorpublichealthproblemindevelopingcountries.Managementofpatientswithspinaldysraphismiscomplexandneedscloseco-ordinationbetweenpediatrician,neurologist,neurosurgeonandrehabilitationexpertsandalsoalargenumberoffactorsinfluencetheoutcome.
178. SPORADIC MENINGIOMATOSIS AS A CAUSE OF STATUS EPILEPTICUS IN CHILDREN: A CASE REPORTZulmaSarahTovar-Spinoza,MD;YamanEksioglu,MD,PhD;DavidCarter,MD;PaulKent,MD(Syracuse,NY)INTRODUCTION: Meningioangiomatosisisararebenignrareconditionobservedsporadicallyorwithneurofibromatosis.Sporadiccasespresentasmedicallyrefractorylocalizationrelatedepilepsy.METHODS: A2year-oldright-handedhealthy,non-NF2,Caucasiangirlpresentedwithstatusepilepticus,leftfocalmotorseizuresandpersistentlefthemiparesis.RESULTS: EEGandlong-termvideo-EEGmonitoringrevealedseizuresinvolvingrightfrontal-temporalregions.Despiteseizurecontrolonlevetiracetam,lacosamide,pyridoxineandclonazepamshehadresistantlefthemiparesis.BrainMRIrevealedrightfrontalarachnoidcyst,adjacentcorticalthickening,T2/FLAIRsignalinadjacentwhitemattersuggestingcorticaldysplasiaandparamedianrightfrontalhypoattenuationsuggestingencephalomalacia.MRSshowednormalNAA/creatineandcreatine/cholineratios.Duetorefractoryepilepsy,invasivemonitoringwasperformed.Seizureonsetwasconfirmedfromtherightfrontalcorticaldysplasiaandtheadjacentcortex.Sheunderwentsensory/motormappingandcorticographyfollowedbypartialrightfrontallobectomy.Lefthemiparesisresolvedimmediatelypostsurgically.Histopathologyrevealedproliferationofanastomosingspindlecellstrandswithsmallcentralbloodvesselsinvolvingcorticalparenchyma.Abnormalspindlecellswithfibroblastic,meningothelialappearancearosefromtheoverlyingmeningeswithextensionintocorticalparenchymainvolvinggreyandadjacentwhitematterwithareasofnecrosisandsubarachnoidhemorrhage.Patientisseizure-freesinceresectionofthelesion.CONCLUSIONS: Sporadicmeningioangiomatosisisuncommon.MRIfindingsarevariableandcansuggestcorticaldysplasia.Histopathologicaldiagnosisisrequiredassurgicalresectioncanbecurativeincaseswithrefractoryepilepsy.
179. SURGICAL MANAGEMENT OF INTRACRANIAL CAPILLARY HEMANGIOMAS IN CHILDRENPaulA.Grabb,MD(ColoradoSprings,CO)INTRODUCTION: Wedescribethemagneticresonanceimaging(MR),intraoperativefindings,angiographicdetails,andsurgicalmanagementoftwochildrenwithcapillaryhemangiomasofthebrain.METHODS: Twochildren,agesfourteenandninepresentedwithsymptomsconsistentwithelevatedintracranialpressure.Imagingrevealedwelldemarcatedbrightlyenhancinglesionswithconsiderableassociatedperilesionaledema.Imageguidedcraniotomieswereperformed.RESULTS: Bothcaseswerehaltedintraoperativelybythesurgeonbecauseofthefindingsofanintenselyvascularlesionconsistentwithapossiblearteriovenousmalformation(AVM).Bothchildrenweretakenfromtheoperatingroomtotheangiographicsuite.Angiographywasprecededbycomputerizedtomography(CT)intheteenbecauseofworseningintraoperativebrainswelling.Angiographydisplayedasubtleblushinthecapillaryphaseofonelesion,andessentiallynothingintheother.TheCTshowedspontaneoushemorrhagemedialtothelesionexacerbatingthepreexistingbrainedemaintheteen.Bothchildrenwerereturnedpromptlytotheoperatingroomandacompleteexcisionofthelesionperformed.CONCLUSIONS: MRfindingswerecharacteristicforcapillaryhemangiomainretrospect.PreoperativerecognitionofMRfindingscanprovidevaluableassuranceastothenatureofthelesion.AngiographyprovidedassurancethatthelesionswerenotAVMs.IfconfidentoftheMRfindingsangiographymaynotbenecessary.Thesurgeonshouldbepreparedtodealwithsignificantbrainswellingandspontaneoushemorrhagewiththeselesions.
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180. SURGICAL MANAGEMENT OF PEDIATRIC EPIDURAL HEMATOMAS IN THE ERA OF TELERADIOLOGYJulianJ.Lin,MD;AhmadDerekMartinez,MD;BrandonBond,BA(Peoria,IL)INTRODUCTION: Theoutcomesofchildrenwithsurgicalcranialpediatricepiduralhematomas(EDH)aregenerallygoodprovidedthatthehematomasareevacuatedinatimelyfashion.Teleradiologyprovidesphysicianstheabilitytoevaluateimagingpriortopatientarrivalandcanleadtodecreasedintervalbetweenarrivalandevacuation,perhapsleadingtoimprovedoutcomeforpatients.METHODS: Retrospectivereviewof30consecutiveoperatedpediatricepiduralhematomasbetween2004-2012.RESULTS: Therewere22boysandeightgirlswithmeanageofsevenyears.Etiologiesincludedsportsaccidents,falls,andmotorvehiclecollisions.Mostpatientspresentedinitiallytootherhospitalspriortotransfer.PresentingfindingsincludedGCSrangingfrom8to15,anisicoria,vomiting,andlethargy.Seventeenofthirty(57%)patientswereadmittedtotheICUforobservationandunderwentevacuationofEDHinadelayedfashion.Ten(33%)patientswenttotheoperatingroom(OR)fromtheemergencydepartment(ED)foremergentevacuationwhilethree(10%)wenttotheORdirectlyuponarrival.Teleradiology(PACS)becameavailablein2010allowingaccesstoheadCTsperformedatthetransferringinstitution.InthegroupwithoutPACSavailabilityeightwenttotheEDthentotheORwhileonewentdirectlytotheOR.InthegroupwithPACSavailabilitytwowenttotheEDfirstandtwowentstraighttotheOR.Atthreemonthfollow-up5of30patientshadresidualdeficits.CONCLUSIONS: TeleradiologyexpeditedtheprocessofinterventioninchildrenwithEDHandlikelyimprovedtheiroutcomes.
181. SWELLING-PRONE VS. NON-SWELLING-PRONE INJURIES: EFFECTS OF A PATHOANATOMIC-BASED MANAGEMENT ALGORITHMAnn-ChristineDuhaime,MD;PamelaStuartJones,MD;SharonHaire,NP;RimaSestokas,BS;SarahMurphy,MD;ElizabethShannon,NP;CarenHarris,NP;AliceGervasini,PhD;PeterMasiakos,MD;GeorgeVelmahos,MD,PhD(Boston,MA)INTRODUCTION: Triageandmanagementdecisionsinpatientswithheadinjuryandpolytraumacanpresentchallengeswhenmultipleindividualsandteamsareinvolvedincare.MostguidelinesdependoninitialGlasgowComaScore,whichcanhavelimitedspecificitybecauseofprehospitalcareandvaryingevolutionofdifferentpathoanatomicinjuries.AtourLevel1TraumaCenterweimplementedahospital-widetriageandmanagementalgorithmwhichincludesgroupinginjuriesintoswelling-proneandnon-swelling-pronecategories,andassesseditseffectsoninterdisciplinarycommunicationandtreatment.METHODS: Thealgorithmreflectshowneurosurgicaldecisionstypicallyaremade,basedonspecificfeaturesofthehistory,exam,andimaging,andincorporatesknowledgeaboutdifferencesamongpathoanatomicinjurytypeswithrespecttorisksofdeteriorationintheacuteperiod.Wecompareda)frequencyofcommunicationsissuesaboutheadinjurymanagementdiscussedatMultidisciplinaryTraumaCaseConference,andb)radiologicimagingfrequencywithCTscansbeforeandafterinstitutionofthealgorithmforpatientsyoungerthan20.RESULTS: Inthesurveyedperiodpriortoinstitutionofthealgorithm,headtraumatriageandmanagementissueswereincludedin50%ofallcasequalityreviews.Inthepost-algorithmperiod,thisnumberdecreasedtolessthan10%.TotalnumberofCTscansobtainedoncomparablepopulationsofadmittedheadtraumapatientsdecreasedoverthisintervalaswell.CONCLUSIONS: Simplealgorithmsthatincorporatepathoanatomicfeatures,ratherthanjustacuteinjuryseverityscore,canbehelpfultoalignexpectationsaboutmanagement,reduceunnecessaryradiationexposure,andfocusoninterventionstargetedtowardspreventionofpredictablecomplications.
182. TECTAL GLIOMAS: NATURAL HISTORY AND PROGRESSION OF THE DISEASEEliasB.Rizk,MD;ShaneTubbs;JerryOakes,MD;MarkDias,MD;JamesJohnston,MD;JeffreyBlount,MD;JohnWellons,MD,MSC;CurtisRozzelle,MD(Harrisburg,PA)INTRODUCTION: Tumorsinvolvingthetectumconstituteadistinctsubgroupofbrainstemgliomasusuallywithanindolentcourse.METHODS: ChartreviewandimagingcharacteristicswerereviewedinpatientswhopresentedwithtectalplategliomasandprogressionofdiseasewasevaluatedoverthefollowupperiodattheChildren’sHospitalofAlabamafrom1993-2012.RESULTS: 14numberofpatientswerefollowedupformeanof4.9years.TumorprogressionwascalculatedusingserialMRIimagingseeninallnumberofpatientsasperradiographicevidence.OnlyonepatienthadprogressionofdiseasethatrequiredsurgicalresectionCONCLUSIONS: Basedonourexperience,tectalplategliomasinthepediatricagegroupwithouttumorextensionorcontrastenhancementcanbemanagedconservativelyandfollowedwithregularMRIscans.
183. THE INCIDENCE AND NATUAL HISTORY OF PSEUDOMENINGOCELES FOLLOWING CHIARI I DECOMPRESSIONVikramChakravarthy;UsiakimiIgbaseimokumo,MD;DougRivard,DO(KansasCity,MO)INTRODUCTION: Chiaridecompressionisoftenasscociatedwithcerebrospinalfluidrelatedcomplications.Theincidenceandnaturalhistoryisvariableduetothelackofcommondefinitions.AsingleinstitutionexperienceofCSFrelatedmorbidityfollowingChiaridecompressionisdescribedtodeterminetrueincidenceandnaturalhistory.METHODS: Aretrospectivecohortanalysisofaconsecutiveseriesofpatientstreatedoverfiveyears(2007-2011)withMRidefinitionofincidenceandnaturalhistory.UnivariateanalysisofdemographicdataincludingBMIandlogisticregression(SPSS)wasusedtodeterminethepredictorsofpseudomeningocelesanditsnaturalhistory.RESULTS: Inall38patientswereeligibleforthestudyduringthefiveyearperiodandthemeanagewas7years(range1-15years)with21females.TheincidenceofpseudomeningoceleonMRiwas37%butonlytwoCSFleak(5.3%).Most(50%)pseudomeningocelesresolvedspontaneouslyatupto2yearsbutreoperationforallreasonswas20%(8patients).TimesincesurgeryandtheBMIweresignificantlyassociatedwiththeprevalenceofpseudomeningocele.Therewerenoassociationswithsurgicaltechniqueincludingtheuseofallogenicgrafts.CONCLUSIONS: TheincidenceofpseudomeningoceleishighfollowingChiariIdecompressionandthereisaneedtostandardizeboththeMRIdefinitionandpostoperativefollow-uptoconfirmwhatfactorsarepredictiveofneedforre-operation.
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184. THE ROLE OF ANEURYSM SYBTYPE IN THE LONG TERM NEUROLOGICAL OUTCOME OF PEDIATRIC ANEURYSM-ASSOCIATED AVM PATIENTSChristopherPaulKellner,MD;MichaelMcDowell,BS;KevinNaranjo,BS;EricSussman,BS;RachelBruce,BA;SamBruce,MS;SimonHeuts,BS;RichardAnderson,MD(NewYork,NY)INTRODUCTION: Thereismuchdebateabouttherolethataneurysmsplayintheriskofintracerebralhemorrhage(ICH)whenassociatedwithArteriovenousMalformations(AVMs)inthepediatricpopulation.Preliminarycohortshavesuggestedthatconcurrencedoesnotincreasetheriskofhemorrhageorpredictlong-termoutcomes.However,thesestudiesrarelydifferentiatedbyaneurysmtype.Wesoughttoassesstheriskofhemorrhageandpooroutcomewhenaneurysmswereseparatedintoarterialandnon-arterialsubtypes.METHODS: Twenty-fourpatientswithaneurysm-associatedAVMsweretreatedattheColumbiaUniversityMedicalCenterbetween1991and2011.Medicalrecordsandimagingstudieswereretrospectivelyreviewedandseparatedbyaneurysmsub-type.ClinicaloutcomebasedonthemodifiedRankinScale(mRS)andriskofICHwerecomparedbetweenthetwosubtypes.RESULTS: Ofthe24patients,11hadarterialaneurysms(45.8%)and13hadnon-arterialaneurysms(54.2%).TenpatientswitharterialaneurysmspresentedwithICH.Fourpatientswithnon-arterialaneurysms(30.8%)presentedwithICH(p<0.01).ThemeanmRSonadmissionwas2.55and0.54onfollowupforthearterialgroup.ThemeanmRSonadmissionwas1.54and1.27onfollowupforthenon-arterialgroup.FollowupmRSwasnotsignificantlydifferent(p=0.102).CONCLUSIONS: AVM-associatedaneurysmsofanarterialnaturemaybemorelikelytopresentwithhemorrhage,butmaynotpredictaworseoutcomethanthosewithonlynon-arterialaneurysms.Thismaybeduetothelowpowerofthestudy,apredominantlyAVM-associatedriskofhemorrhage,oraggressivemanagementofpatientswithAVM-associatedaneurysms.
185. THE CERVICAL SPINE IN KLIPPEL-FEIL SYNDROME: A NATURAL HISTORY STUDYEliasB.Rizk,MD;ShaneTubbs,PhD;JerryOakes,MD;CurtisRozzelle,MD;JeffreyBlount,MD;JohnWellons,MD;JoshMenendez,MD;JamesJohnston(Harrisburg,PA)INTRODUCTION: Klippel-Feilsyndromemaybeassociatedwithhypermobilityofthecervicalspinebetweenthefusedsegments.METHODS: AchartreviewwasperformedonallpatientsseenandevaluatedattheChildren’sHospitalofAlabamabetween1993and2012.Asymptomaticpatientswithcervicalspineinstabilitywerechosenandanaveragefollowupperiodwascalculated.RESULTS: 52patientswereidentifiedfromthedatabankwiththediagnosisofKlippel-Feilsyndrome.25patientswereidentifiedwithadequateflexionextensionfilms.Imagingshowedevidenceofadjacentlevelhypermobilityin23patients.Noneoftheidentifiedpatientsunderwentprophylacticcervicalimmobilization.Noneofthepatientsdevelopedworseningneurologicsignsorsymptomsoverthecourseofthefollowup.CONCLUSIONS: Basedonourexperience,non-operativemanagementandexpectantobservationisareasonableoptioninpatientswithKlippel-Feilsyndromeandcervicalinstabilitywithoutneurologicinvolvement.
186. TIME TO FAILURE FOR FIRST-TIME SHUNTS IN CHILDREN AGED FIVE YEARS AND OLDERKevinCarr;AtoWallace,BS;LukeTomycz,MD;NoelTulipan,MD(Nashville,TN)INTRODUCTION: Theone-yearfailureratefornewlyinsertedventriculoperitonealshuntsinthepediatricpopulationhasbeenreportedinnumerousseriestobeashighas40%.Ageattimeofshuntinsertionhasbeenshowntobeasignificantfactorinshuntsurvival.METHODS: UsingCPTcodesandbillingrecords,weidentifiedallthepatientswhounderwentventriculoperitonealshuntingatVanderbiltChildren’sHospitalbetween1997and2012.Weexcludedallchildrenwhowereunderagefiveatthetimeoffirstshuntinsertion.WethenreviewedtheStarpanelTMelectronicchartsystemtodeterminetheindicationforshunting,thepercentageofshuntsthatfailed,themeanaveragetimetofailure,andthetotalfollow-uptime.RESULTS: Atotalof121patientswereincludedwithanaverageageof11.67years(SD=4.01).Indicationsforshuntinsertionincludedidiopathicintracranialhypertension(20.7%),tumor(49.6%),andhemorrhage(11.6%),amongothercauses.Overall26.4%ofthecohortexperiencedshuntfailurewithameantimetofailureof437.27daysandanaveragetotalfollow-upof711days.Ofthe16patientswhodevelopedfailures,10wereduetoinfection,1duetooverdrainageandtherestwereduetomechanicalobstructionofeithertheproximalcatheter,distalcatheter,orvalve.CONCLUSIONS: First-timeshuntinsertioninchildrenfiveyearsofageorolderisassociatedwitharelativelylowfailurerateattwoyears.
187. TRANSTENTORIAL STENT INSERTION IN THE MANAGEMENT OF ISOLATED FOURTH VENTRICLEJothyKandasamy,MD;RussellFrood;JerardRoss,MD;MuhammadDherijha,MD(Leeds,UnitedKingdom)INTRODUCTION: Isolatedfourthventricleisanuncommoncondition.Thereareseveraltechniquesdescribedforitsmanagement.Thesemethodsareassociatedwithvariousbenefitsandcomplications.Thispresentationillustratestheuseoftranstentorialstentingasanoptionforthemanagementofthiscondition.METHODS: AretrospectivecaseseriesstudyofpatientswhohadatranstentorialstentplacedattheRoyalHospitalforSickChildren,Edinburghbetween2011and2012.Patient’notes,surgicaldatabaseandradiologicalimagingwerereviewed.Therewerethreepatientswhounderwentthisprocedure;onepatientrequiringtheproceduretwiceleadingtothefourcasespresented.RESULTS: Noneofthepatientssufferedfromperioperative/immediatepostoperativecomplications.Onepatientrequiredtheirstenttoberemovedandthenlaterreplacedduetoadelayedpresentationofshuntinfection.AllpatientshadareductionintheirfourthventriclesizedemonstratedradiologicallywithMRIorCTandcommensurateclinicalimprovement.CONCLUSIONS: Thiscaseserieshighlightstheviabilityoftranstentorialstentingasasafeandeffectivemanagementoptionforselectedcasesofisolatedfourthventricle.
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188. VERTEBRAL CHORISTOMA IN LIPOMYELOMENINGOCOELE – CASE REPORTShejoyP.Joshua,MD;PankajSingh,MD;AshokMahapatra,MD(NewDelhi,India)INTRODUCTION: Lipomeningocoeleisatypeofoccultspinaldysraphismcharacterisedbyasubcutaneouslipomatousmassthatprotrudesthroughamidlinebonydefect.Wereportrarepresentationofthiscondition-avertebralchoristomawhereinthelipomatousmassdisplacedthenormallyformedposteriorelements-laminaandspinousprocessofL4vertebradorsallytoanabnormallocationintheabsenceofabonydefect.METHODS: Afiveyearoldgirl,presentedtouswithabonyhardswellinginthelowerlumbararea,sincebirth.ALumbo-sacralMRIshowedwasalipomatousmassextendingfromtheconustothesubcutaneousspacewiththespinalcordtethered,conusendingatL5.TherewasanothermassoftheshapeofthelaminaandspinousprocessatexpectedlevelofposteriorelementsofL4vertebra,whichwasisointenseonT1andplacedaround2cmdorsalcomparedtotheposteriorelementsL3andL5.RESULTS: Lipomyelomeningocoeleisararecongenitalconditionwhichmaybeassociatedwithvertebralanomalies.CONCLUSIONS: Thispaperreiteratesourknowledgeoftheembryologicdevelopmentofthespinalcordandprovestheplasticityofthegrowingspinetomalformativeforces.
189. VIDEO DIVERSION DURING FUNDOSCOPIC EXAM IN CHILDREN: A RANDOMIZED CONTROLLED TRIALAshutoshSinghal,MD,FAANS,FRCSC;MichaelYang,MS;JohnKerr,BS(Vancouver,Canada)INTRODUCTION: Fundoscopyisanimportantaspectoftheneurologicalexamination,butcanbechallenginginuncooperativechildren.Thisstudyexploredwhetherviewingavideo(selectedbypatientorcaregiver)duringeyeexaminationimprovesthesuccess,durationandeaseofpediatricfundoscopy.METHODS: Asingle-practitioner,block-randomizedstudywasconductedattheBCChildren’sHospitalPediatricNeurosurgeryoutpatientclinic.Sixtypatients,1-8yearsold,wererandomized(byeyeexamined)totreatmentgroup(video-assistedfundoscopy)orcontrol(non-videofundoscopy).Successfulexamsweredefinedasvisualizingtheopticdiskwithin60s.Bothcaregiversandpractitionerrankedthelevelofdifficultyofeachexam(10-pointLikertscale).RESULTS: 33femaleand27malesubjectswereenrolled,withamedianageof3.7years.Therewasa28%absoluteimprovementinthesuccessrateofvisualizingtheopticdisk(video-90%successvs.non-video62%,p<0.001).Furtheranalysisshoweda48%absoluteimprovementinsuccessrateinchildren1-4yearsofage(p<0.001),butnodifferenceinchildren5-8yearsold(p=0.23).Timeneededtovisualizetheopticdiskalsoimproved(Δ16.3s,p<0.001).Animprovementineaseofexamination(p<0.001)wasnotedbybothexaminerandcaregiver.CONCLUSIONS: Videosweresuccessfulatimprovingtheease,time,andmostimportantly,successoffundoscopyinchildren.Therewasnoeffectonsuccessrateinolderchildren,buttimeandperceiveddifficultyimproved.Thissimple,inexpensiveadjuncttotheophthalmologicalassessmenthasgreatpotentialtoimprovetheeaseandefficacyofthisaspectofthepediatricneurologicalexamination.
190. WORSENING OR DEVELOPMENT OF SYRINGOMYELIA FOLLOWING CHIARI I DECOMPRESSIONRobertPartlowNaftel,MD;RTubbs,PhD;JohnWellons,MD,MPH;IanPollack,MD;WOakes,MD(Pittsburgh,PA)INTRODUCTION: TheeffectsofposteriorfossadecompressiononChiariinducedsyringomyeliahavebeenwelldescribed.However,treatmentofworseningsyringomyeliaafterChiaridecompressionremainsenigmatic.METHODS: AretrospectivereviewofpatientsattheChildren’sHospitalofPittsburghandChildren’sofAlabamawhodevelopedworseningsyringomyeliaafterChiaridecompressionwasperformed.RESULTS: Fourteenchildren(agerange8monthsto15years),halfofwhomhadpreoperativesyringomyelia,underwentposteriorfossadecompression.Asepticmeningitis(n=3)andbacterialmeningitis(n=2)complicated5cases(4wereoriginallytreatedatoutsidehospitals).Worseningsyringomyeliapresentedamedianof1.4years(range0.3-10.3years)aftertheprimarydecompression.Tenchildrenpresentedwithnew,recurrent,orpersistentsymptoms,and4wereasymptomatic.SecondaryChiaridecompressionwasperformedon11ofthe14children.Theother3wereadvisedtoundergosecondarydecompression.AstructuralcauseforeachfailedprimaryChiaridecompressionwasidentified(e.g.,extensivescarring,sutureintheobex,arachnoidweb,residualposteriorarchofC1,noduraplasty).Aftersecondarydecompression8patients’symptomscompletelyresolved,onepatientstabilized,andtwopatientsremainedasymptomatic.Radiologically,syrinxsizedecreasedin10of11children.Medianfollow-upfrominitialChiaridecompressionwas3.1years(range0.8-14.1)andfromsecondarydecompression,1.3years(range0.3-4.5).Nopatientunderwentasyringopleuralshuntorothernon-posteriorfossatreatmentforsyringomyelia.CONCLUSIONS: Basedonourexperience,childrenwithworseningsyringomyeliaafterChiariIdecompressionshouldbetreatedwithsecondarydecompressions.
191. YOUTUBE AND HYDROCEPHALUS: CONTENT QUALITY, RELIABILITY, AND COMPREHENSIVENESSRobertPartlowNaftel,MD;JeffreyBlount,MD(Pittsburgh,PA)INTRODUCTION: Increasingly,caregiversandpatientsrelyontheInternetandsocialmediaformedicalinformation.YouTubeisthemostwidelyutilizedInternetaudiovisualinterface.Thisstudyexaminesthequality,reliability,andcomprehensivenessofhydrocephalus-relatedYouTubevideos.METHODS: YouTubewassearchedforthekeywordhydrocephalus.Thefirst176videos(10pages)werejudgedindependentlyby2neurosurgeonsandcategorizedasuseful(scientificallycorrectinformation),misleading(unprovenorinaccurate),orpersonalexperiences/patientviews(testimonials,awareness,support).On5-pointscales,allvideoswerescoredforcontentquality(QS),andusefulvideoswerescoredforreliability(RS)andcomprehensiveness(CS).RESULTS: Of176videoswatched,62wereeliminatedduetoexclusioncriteria.Themajorityofvideoswereproducedbyindependentusers(61/114),physicians/universities(18/114),professionalsocieties(20/114),andtheremainderbygovernmentagencies,newsagencies,pharmaceutical/devicecompanies,orhealthwebsites.Videosprimarilytargetedpediatrichydrocephalus(107/114)andwereintendedforlayaudiences(108/114).Of114videos,53wereusefuleducationalvideos(QS2.7+/-0.8),9weremisleading(QS1.9+/-0.6),and52werepersonalexperiences(QS1.9+/-0.5).Usefulvideosweremoderatelycomprehensive(CS2.4+/-1.4)butnotveryreliable(RS1.7+/-1.2).Allpersonalexperiencevideosreflectedpositivelyandeitherprovidedemotionalsupportordiseaseawareness.CONCLUSIONS: Nearlyhalfofhydrocephalus-relatedYouTubevideoswereuseful,educationalvideosandveryfewweremisleading;however,overallquality,reliability,andcomprehensivenesswerelow.Theotherportionofvideosprovidedemotionalsupportandincreaseddiseaseawarenessthroughtestimonialsandvideosofsolidarity.
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192. ANTI-CD47 THERAPY AS A COMMON THERAPEUTIC TARGET FOR PEDIATRIC BRAIN TUMORSSamuelH.Cheshier,MD,PhD;ShararehGholamin,MD;SiddharthaMitra,PhD;ChaseRichard,BS;AbdullahFeroze,BS;Do-SikKong,MD;TalRaveh,PhD;MichelleMonje,MD,PhD;Yoon-JaeCho,MD,PhD;MichaelEdwards,MD;IrvingWeissman,MD;SamuelCheshier(Stanford,CA)INTRODUCTION: Acharacteristicfeatureoftumorprogressionandrecurrenceisitsabilitytoevadetheimmunesystem.Ourhypothesisisthatbymodulatingtheinnateimmunesystemwecanenhancetheabilityofmacrophagesto‘eatandkill’braincancercells.RecentdatasuggeststhattheinteractionbetweenthecellsurfaceantigenCD47anditsbindingpartnerSirp-alphaisamechanismbywhichnon-solidandsolidtumorscanevadetheinnateimmunesystem.METHODS: Toseeifanti-CD47therapyisapotentialtherapyinmalignantpediatricbraintumorswefirstlookedatCD47expressioninfreshlyisolatedpatientandpostmortemsamplesfrom4differenttumortypes;DiffusedIntrinsicPontineGlioma,Medulloblastoma,EpendymomaandATRTs.Wenextestablishedorthotopicxenograftsmodelsinimmunecompromisedmiceandtreatedthemwithanti-CD47humanizedantibody,whichiscurrentlybeingdevelopedforclinicaltrialsinhematopoieticandnon-CNSmalignancies.RESULTS: CD47expressionwasupregulatedinalltumortypesandwaspresentin<90%ofthecellsinhighgradetumor.IncreasedCD47expressionwasobservedinCD15+andCD133+putativecancerstemcellpopulation.BlockingtheCD47-Sirp-alphainteractionincreasestumorphagocytosisbymacrophagesin-vitro.Systemictreatmentwithanti-CD47antibodysignificantlyreducedtumorburdeninanorthotopicxenograftmodel.CONCLUSIONS: Anti-CD47antibodyhaspotentanti-tummoreffectsinourpreclinicalmodelsofpediatricbraintumors.
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SECTION MEMBERSHIP ROSTER (AS OF OCTOBER 31, 2012)
Rick Abbott, MDChildrensHospitalatMontefiore3316RochambeauAveBronx,NY10467-2841
Jafri Malin Abdullah, MD, PhDHospitalUniversitiSainsMalaysiaNeurosciencesJalanSultanahZainab2KotaBharuKelantan,16150Malaysia
Sergey Abeshaus, MD4800SandPointWayNEPOBox5371Seattle,WA98105-0371
Laurie Lynn Ackerman, MD7614SpringRidgeDrIndianapolis,IN46278-9618
P. David Adelson, MDPhoenixChildren’sHospital1919EThomasRdBldgBPhoenix,AZ85016-7710
Shameem Ahmed, MDHouse#227/Type3QTRAvNagarCampus/AIIMSHosp.NewDelhi,110049India
Edward S. Ahn, MDJohnsHopkinsHosp./Neurosurgery600N.WolfeSt.Harvey811Baltimore,MD21287-0001
Hazem Akil, MDMacquarieUniv.Hosp./Neurosurgery2TechnologyPlSydney,NSW2109Australia
Philipp R. Aldana, MDPavilionBuilding836PrudentialDr.Ste.1005Jacksonville,FL32207-8334
Tord D. Alden, MDChildren’sMem.Hosp./Neurosurgery2300Children’sPlazaBox28Chicago,IL60614
Alex Alfieri, MDKlinikundPoliklinikfürNeurochirurgieErnst-Grube-Str.40Halle(Saale),06097Germany
Ghanem Al-Sulaiti, MDPOBox1870Doha,Qatar
Lance Luke Altenau, MD21005thAveSte200SanDiego,CA92101-2102
A. Loren Amacher, MD3HospitalDrLewisburg,PA17837-9362
Sudheer Ambekar, MD1013QuailCreekRoadApartmentFShreveport,LA71105
Richard C. E. Anderson, MDNeurologicalInstitute710W168thStRm213NewYork,NY10032-3726
Jim D. Anderson, MDPOBox658SanCarlos,CA94070-0658
Brian T. Andrews, MD45CastroStSte421SanFrancisco,CA94114-1031
Patricia A. Aronin, MD, MS1301BarbaraJordanBlvdSte307Austin,TX78723-3080
Elaine J. Arpin, MD
Wilson T. Asfora, MD1210W18thStSte104SiouxFalls,SD57104-4650
Kurtis Ian Auguste, MDM779Box0112505ParnassusAve.SanFrancisco,CA94143-0001
Anthony Michael Avellino, MD, MBAHarborviewMed.Ctr./Neurosurgery3259thAve#359766Seattle,WA98104-2420
Saleh S. Baeesa, MBChBKingAbdulazizUniversityHospitalDivisionofNeurologicalSurgeryJeddah,21589SaudiArabia
Walter L. Bailey, MD500RiverStMinneapolis,MN55401-2542
Lissa Catherine Baird, MDOHSU/Dept.ofNeurosurgery3303SWBondAve/MCCH8NPortland,OR97239
Gene A. Balis, MDNeurologicalSurgeonsAssociates3000EFletcherAveSte340Tampa,FL33613-4645
Benedicto Cortes Baronia, MDUERM/NeurosurgeryRoom241@FAuroraBlvd.QuezonCity,1113Philippines
Luigi Bassani, MDNewYorkUniv.Med.Ctr.5501stAveNewYork,NY10016-6402
David Frederick Bauer, MDOneMedicalCenterDr.Lebanon,NH03756
Andrew Michael Bauer, MDUniv.ofWisconsin-Madison/Neurosurgery600HighlandAve.Rm.K4/822Madison,WI53792-0001
James E. Baumgartner, MD615EPrincetonStSte540Orlando,FL32803-1424
Robert Micheal Beatty, MD12200W106thStSte400OverlandPark,KS66215-2305
William O. Bell, MDNeurosurgicalAssoc.oftheCarolinas2810MaplewoodAveWinstonSalem,NC27103-4138
Ethan A. Benardete, MD, PhDThomasJeffersonUniv./Neurosurgery900WalnutSt.Philadelphia,PA19107
Benjamin G. Benner, MDNeurosurgerySpecialists6767SYaleAveSteATulsa,OK74136-3303
Mitchel S. Berger, MDUCFS/Dept.ofNeurosurgery505ParnassusAve.M-786SanFrancisco,CA94143-0001
Jose A. Bermudez, MD301HallStMonroe,LA71201-7526
Bryan Bertoglio, MD800BiesterfieldRdSte610ElkGroveVillage,IL60007-3362
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SECTION MEMBERSHIP ROSTER
William B. Betts, MD3218ParkHillsDrAustin,TX78746-5573
Sanjiv Bhatia, MDMiamiChildren’sHosp.3100SW62ndAveSte3109Miami,FL33155-3009
Karin Sabin Bierbrauer, MDCincinnatiChildren’sMed.Ctr.3333BurnetAveCincinnati,OH45229-3026
Peter M. Black, MD, PhD13LouisburgSqBoston,MA02108-1202
Jeffrey P. Blount, MDChildren’sHospitalofAlabama16007thAveSAcc400Birmingham,AL35233-1711
John Scott Boggs, MD3ShircliffWaySte104Jacksonville,FL32204-4785
Frederick A. Boop, MDSemmesMurpheyClinic1211UnionAveSte200Memphis,TN38104-6654
Robin M. Bowman, MDChildren’sMemorialHosp.2300Children’sPlaza#28Chicago,IL60614
William R. Boydston, MDPediatricNeurosurgeryAssoc.5455MeridianMarksRdNESte540Atlanta,GA30342-4723
Taryn McFadden Bragg, MDDept.ofNeurosurgery/K4-830600HighlandAve.Madison,WI53792-0001
Ruth E. Bristol, MDPhoenixChildren’sHospital1919EThomasRdBldgBPhoenix,AZ85016-7710
Douglas L. Brockmeyer, MDPrimaryChildren’sMed.LCtr.100MarioCapecchiDr#1475SaltLakeCity,UT84113-1103
Jeffrey A. Brown, MD600NorthernBlvdSte118GreatNeck,NY11021-5200
Derek A. Bruce, MD2577TownshipRdQuakertown,PA18951-3350
Michael James Burke, MDNeurosurgeryInst.ofSouthTexas3643SStaplesStCorpusChristi,TX78411-2456
George T. Burson, MDNeurosurgeryArkansas9601LileDrSte310LittleRock,AR72205-6325
Neil Buxton, MDDept.ofNeurosurgeryWaltonCentreLowerLn.Liverpool,97UnitedKingdom
Leslie D. Cahan, MD16063RoyalOakRdEncino,CA91436-3913
Jeffrey W. Campbell, MDDupontHosp.forChildren1600RocklandRdWilmington,DE19803-3607
Carolyn Marie Carey, MD6015thStS#511SaintPetersburg,FL33701-4804
Peter W. Carmel, MDUMDNJ-NewJerseyMed.Sch.90BergenStSte7300Newark,NJ07103-2425
Benjamin Solomon Carson, MDJohnsHopkinsUniv.Hosp.600N.WolfeSt.Harvey811Baltimore,MD21287-0001
Alexandre Casagrande Canheu, MDClinicaRenovatioRuaHumaitá#742Cianorte,87200000Brazil
Oguz Cataltepe, MDDiv.ofNeurosurgery55LakeAveNSteS2-848Worcester,MA01655-0002
Jeffrey E. Catrambone, MD90BergenStRm8126Newark,NJ07103-2425
Juanita Marie Celix, MDHarborviewMed.Ctr./NeurologicalSurg.3259thAve#359924Seattle,WA98104-2420
Michael J. Chaparro, MDSouthFloridaNeurosurgicalandSpinalW12983SouthernBlvdSte202Loxahatchee,FL33470-9207
William R. Cheek, MD3009RobinhoodStHouston,TX77005-2343
Joshua J. Chern, MD, PhD16007thAveS#ACC400Birmingham,AL35233-1711
W. Bruce Cherny, MD100EastIdahoSt.Ste.202Boise,ID83712-6270
David A. Chesler, MD, PhDUniv.ofMaryland/Neurosurgery22SGreeneSt#S12Baltimore,MD21201-1544
Maurice Choux, MD14avSolvertCMarseille,13009France
Giuseppe Cinalli, MDNeurosurgery-SantobonoChildrensHospitalViaMarioFioren.6Naples,80129Italy
Samuel F. Ciricillo, MD2800LStSte500Sacramento,CA95816-5616
David Douglas Cochrane, MDChildrens&WomensHlth.Ctr.ofBCB2W4500OakSt.Vancouver,BCV6H-3N1Canada
Patrick James Codd, MDMassachusettsGen.Hosp./Neurosurgery55FruitSt#Wh502Boston,MA02114-2621
Alan R. Cohen, MDChildren’sHosp.Boston300LongwoodAveHunnewell2Boston,MA02115-5724
John Jeffrey Collins, MDWestVirginiaUniv.HscPOBox9183Morgantown,WV26506-9183
Shlomo Constantini, MD, MScDanaChildren’sHospital/TelAvivMed.Center6WeizmanSt./Ped.Neurosurg.TelAviv64239Israel
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SECTION MEMBERSHIP ROSTER
Daniel Edward Couture, MDMedicalCenterBlvd.WakeForestUniv./BaptistMed.Ctr.WinstonSalem,NC27157-0001
Kerry R. Crone, MDChildrensHosp.Med.Ctr./Neurosurgery3333BurnetAve.Ml2016Cincinnati,OH45229
Daniel J. Curry, MD6621FanninCCC1230.00Houston,TX77030
Moise Danielpour, MDCedars-SinaiHealthSystems8631W3rdStSte800ELosAngeles,CA90048-5929
Robert C. Dauser, MDTexasChildren’sHospital6621FanninStSte950Houston,TX77030-2303
Laurence Davidson, MD8901WisconsinAvenueBldg9,1stFL,NeurosurgeryNationalNavalMedicalCtr,MD20889
Richard A. A. Day, MDMontanaNeurosurgeryCtr.2835FortMissoulaRdSte202Missoula,MT59804-7424
Mark S. Dias, MDPennsylvaniaStateMed.Sch.500UniversityDrHershey,PA17033-2360
Roberto Jose Diaz, MDUniv.ofCalgary/Neurosurgery1403-29thSt.N.W.Rm.C1249Calgary,ABT2N-2T9Canada
John R. Dickerson, MDAbayNeuroscieneCenter3223NWebbRdSte1Wichita,KS67226-8176
Joseph F. Dilustro, MDChildren’sHospital601ChildrensLnSte5ANorfolk,VA23507-1910
Arthur J. DiPatri Jr., MDChildren’sMem.Hosp./Ped.Neuro.2300Children’sPlazaBox28Chicago,IL60614
Peter B. Dirks, MDHospitalforSickChildren555UniversityAve.Toronto,ONM5G-1X8Canada
Concezio Di Rocco, MDUniv.Cattolica/NeurochirurgiaLargoGemelli8Rome,00168Italy
David J. Donahue, MDNeurosurgeryServices8017thAveSte120FortWorth,TX76104-2733
Agustin Dorantes, MD#330AvenidaCuauhtemocMexicoCity,BCN06720Mexico
James R. Doty, MDStanfordNeurosurgeryOutreach2490HospitalDrSte106MountainView,CA94040-4117
James M. Drake, MD#1504555UniversityAve.Toronto,ONM5G-1X8Canada
Bernt Johan Due-Tonnessen, MDRikshopsitaletMedicalCenterDept.ofNeurosurgeryOslo,0027Norway
Ann-Christine Duhaime, MDMGH/PediatricNeurosurgery15ParkmanStBldg331Boston,MA02114-3117
John A. Duncan III, MD, PhDDept.ofNeurosurgery1150VeteransBlvdRedwoodCity,CA94063-2037
Charles Cecil Duncan, MDYaleUniv.Sch.ofMed.333CedarStTmp419NewHaven,CT06510-3206
Mary E. Dunn, MD225SmithAveNSte200SaintPaul,MN55102-2534
Duc H. Duong, MDDivisionofNeurosurgery1000W.CarsonSt.Torrance,CA90502-2004
Susan R. Durham, MDDartmouth-HitchcockMC/Neurosurgery1MedicalCenterDrLebanon,NH03756-1000
Soner Duru, MDDivanResidenceABlok#142IstasyonMahallesi/Halkali/KücükcekmeceIstanbul,34000Turkey
Michael S. B. Edwards, MD300PasteurDrRmR211Stanford,CA94305-2200
Michael R. Egnor, MDNySpine&BrainSurgeryPcNeurosurgery/HscT12-080SunyStonyBrook,NY11794-0001
Stephanie L. Einhaus, MDSemmes-MurpheyClinic6325HumphreysBlvdMemphis,TN38120-2300
Howard M. Eisenberg, MDUniv.ofMarylandMed.Ctr.22SGreeneStSteS12DBaltimore,MD21201-1544
Samer K. Elbabaa, MDSt.LouisUniversity/Neurosurgery1465SGrandBlvdSte3707SaintLouis,MO63104-1003
Mostafa A. El Khashab, MD, PhD20ProspectAveSte905Hackensack,NJ07601-1974
Richard G. Ellenbogen, MD3259thAveMS359766Seattle,WA98104-2420
Ibrahim M. El Nihum, MDScottandWhiteNeuroscienceInstitute2401S.31stStreetTemple,TX76508-0001
Scott W. Elton, MD1432SDobsonRdSte304Mesa,AZ85202-4773
Mark D. Erasmus, MD1123LasLomasRdNEAlbuquerque,NM87106-4524
Walter J. Faillace, MDNNMC/Neurosurgery8901WisconsinAve.Bethesda,MD20889-0001
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SECTION MEMBERSHIP ROSTER
Neil Arthur Feldstein, MDNewYorkNeurologicalInst.710W168thStRm414NewYork,NY10032-3726
Ann Marie Flannery, MD938ChapelOaksRdFrontenac,MO63131-2816
Eldon L. Foltz, MDUCIMed.Ctr./Neurosurgery101CityDr.Bldg.3Rt.81Rm.313Orange,CA92868
Andrew B. Foy, MDChildren’sHosp.ofWI/Neurosurgery999N92ndStSte310Milwaukee,WI53226-4875
Arno H. Fried, MDAdvancedNeurosurgicalAssoc.Pc20ProspectAveSte905Hackensack,NJ07601-1974
David M. Frim, MDUniversityofChicago5841SMarylandAve#Mc3026Chicago,IL60637-1447
Herbert E. Fuchs, MD, PhDDukeUniversityMedicalCenterBox3272Durham,NC27710-0001
Daniel H. Fulkerson, MDRileyHospitalForChildren702BarnhillDrSte1134Indianapolis,IN46202-5128
Joseph H. Galicich, MDPOBox276Alpine,NJ07620-0276
Clare Naomi Gallagher, MDFoothillsMed.Ctr./ClinicalNeurosciences140329thSt.N.W.Calgary,ABT2N-2T9Canada
Hugh J. L. Garton, MD, MHScUniv.ofMichigan/MottChildren’sHosp.1500EMedicalCenterDrAnnArbor,MI48109-5000
Sarah J. Gaskill, MDDept.ofNeurologicalSurgery2TampaGeneralCirTampa,FL33606-3603
Robert T. Geertman, MD, PhDHamannBldg.2500MetrohealthDr.Ste.H-910Cleveland,OH44109-1900
Rosemaria Gennuso, MD4410MedicalDrSte410SanAntonio,TX78229-3749
Timothy M. George, MD1301BarbaraJordanBlvd.#307Austin,TX78723-3077
Steven S. Glazier, MDMUSC/Neurosurgery428CSBPOBox250616Charleston,SC29425-0001
P. Langham Gleason, MD17229thStWichitaFalls,TX76301-5003
Roberta P. Glick, MDMt.Sinai/NeurosurgeryCaliforniaAt15thChicago,IL60608
James T. Goodrich, MD, PhDMontefioreMed.Ctr./Neurosurgery111E210thStBronx,NY10467-2401
Liliana C. Goumnerova, MDChildren’sHospitalHunnewell2300LongwoodAveBoston,MA02115-5724
Lance Shane Governale, MDNationwideChildrensHosp.700ChildrensDr./PediatricNeuro.Columbus,OH43205-2664
Paul A. Grabb, MD1725EBoulderStSte104ColoradoSprings,CO80909-5740
John Andrew Grant, MBChBUniv.ofKansasMed.Ctr.3901RainbowBlvd.Ms3021KansasCity,KS66160-0001
Gerald A. Grant, MDDUMC/PediatricNeurosurgeryBox3272Durham,NC27710
Patrick C. Graupman, MDGilletteChildren’s200UniversityAveESaintPaul,MN55101-2507
Clarence S. Greene, MDNeurosurgery200HenryClayAveNewOrleans,LA70118-5720
Stephanie Greene, MDChildren’sHosp.ofPittsburgh45th&Penn/4thFl.FacultyPavilionPittsburgh,PA15201
Ronald Thomas Grondin, MD, MSc700ChildrensDrColumbus,OH43205-2664
Naina Lynn Gross, MD1000NorthLincolnBlvd.Ste400OklahomaCity,OK73104-3252
David P. Gruber, MD105West8thAve.Ste.200Spokane,WA99204-2318
Raymond W. Grundmeyer III, MDAbayNeuroscienceCtr.3223NWebbRdSte1Wichita,KS67226-8176
Jorge H. Guajardo Torres, MDDoctorsHospitalMedicalCenterEcuador2331-807Monterrey,NLE64623Mexico
Laurance J. Guido, MDPOBox752Siasconset,MA02564-0752
Daniel James Guillaume, MD3303SWBondAveMCCH8NPortland,OR97239-4501
William C. Gump, MD210EGrayStSte1102Louisville,KY40202-3907
Nalin Gupta, MD, PhDUCSF/Neurosurgery/Box0112505ParnassusAve.RmM779SanFrancisco,CA94143-0001
Walter John Hader, MDUniversityofCalgary/Neurosurgery140329thSt.N.W.Calgary,ABT2N-2T9Canada
Yoon Sun Hahn, MDUniv.ofIllinois-ChicagoColl.ofMed.912S.WoodSt./Neurosurg.4thFl.N.Chicago,IL60612
Stephen J. Haines, MDUniv.ofMinnesota/Neurosurgery420DelawareStSEMMC96Minneapolis,MN55455-0341
79
SECTION MEMBERSHIP ROSTER
Mark G. Hamilton, MDFoothillsHospitalDivisionofNeurosurgeryCalgary,ABT2N2T9Canada
Michael Hillel Handler, MDTheChildren’sHospital13123E16thAveAurora,CO80045-7106
William C. Hanigan, MD, PhDUniv.ofMississippiMed.Ctr.2500NStateStJackson,MS39216-4500
Todd Cameron Hankinson, MD, MBAChildren’sHospitalColoradoPediatricNeurosurgeryAurora,CO80045-7106
David Houston Harter, MDNYUPediatricNeurosurgery317E34thStSte1002NewYork,NY10016-4974
Jason Scott Hauptman, MDUCLA/Div.ofNeurosurgeryBox957039LosAngeles,CA90095-0001
Michael D. Heafner, MDCarolinaNeurosurgery&SpineAssoc.225BaldwinAveCharlotte,NC28204-3109
Michael A. Healy, MDNeurosurgicalNetworkInc.2222CherryStSteM200Toledo,OH43608-2674
Ian M. Heger, MD836PrudentialDrSte1005Jacksonville,FL32207-8337
Leslie Carl Hellbusch, MDMidwestNeurosurgery8005FarnamDrSte305Omaha,NE68114-3426
Robert W. Hendee Jr., MD10709RigsbeeCtAustin,TX78739-2008
Martin M. Henegar, MDCarolinaNeurosurgery&SpineAssoc.225BaldwinAveCharlotte,NC28204-3109
Robert D. Hollenberg, MD4WalnutGroveDundas,ONL9H-3M4Canada
John Harrel Honeycutt, MDNeurosurgeryServices1500CooperSt4thFlFortWorth,TX76104-2710
Gregory W. Hornig, MDChildrensMercyHospitals&ClinicsSectionofPediatricNeurosurgeryKansasCity,MO64108-4698
Roger J. Hudgins, MDAkronChildrensHosp./Ped.Neurosurgery1PerkinsSqAkron,OH44308-1063
Robin P. Humphreys, MD67LyndhurstAvenueToronto,ONM5R-2Z8Canada
Sung Kyoo Hwang, MDKyungpookUniv.Hosp./Neurosurgery50SamdukdongChungkuDaegu,700721RepublicofKorea
Mark R. Iantosca, MDPennStateHersheyMed.Ctr./Neurosurgery30HopeDr#EC110Hershey,PA17033-2036
David M. Ibrahimi, MDUniv.ofMaryland/Neurosurgery22SGreeneStRmS12Baltimore,MD21201-1544
Olufemi Emmanuel Idowu, MDLagosStateUniv.Coll.ofMed.NeurosurgeryUnit/Dept.ofSurgeryIkeja/Lagos,234Nigeria
Bermans J. Iskandar, MDUniv.ofWisconsin-Madison600HighlandAve.K4/832Madison,WI53792-0001
Eric M. Jackson, MD700ChildrensDrColumbus,OH43205-2664
George I. Jallo, MDJohnsHopkinsHospital600N.WolfeSt.Harvey811Baltimore,MD21287-0001
Hector E. James, MDWolfsonChildrensHospital836PrudentialDrPavilionBuildingSuite1205Jacksonville,FL32207-8334
John A. Jane Sr., MD, PhDUniv.ofVirginiaHealthSystemBox800212/NeurosurgeryCharlottesville,VA22908-0001
Andrew H. Jea, MD6621FanninStCCC1230.01/12thFlHouston,TX77030-2303
David F. Jimenez, MDUniversityofTexas/Neurosurgery7703FloydCurlDr#7843SanAntonio,TX78229-3901
Rolando Jimenez, MD403Dr.Balmis148MexicoCity,BCN06020Mexico
John K. Johnson, MD223BouchillionDrGreenville,SC29615-6182
Keyne K. Johnson, MDArnoldPalmerHospital83ColumbiaStOrlando,FL32806-1101
Dennis L. Johnson, MDMiltonHersheyMed.Ctr.POBox850Hershey,PA17033-0850
Martin Johnson, MD31870SWCountryViewLnWilsonville,OR97070-7476
Mary Morris Johnson, MD3223ChathamRdNWAtlanta,GA30305-1101
Robert Francis C. Jones, FRCS, FRACSPrinceofWalesPriv.Hosp.BarkerSt./#3Priv.ConsultingRms.Randwick,2031Australia
Allen S. Joseph, MDSte.20010101ParkRoweBatonRouge,LA70810
Kristopher Thomas Kahle, MD, PhDMassachusettsGen.Hosp./Neurosurgery32FruitStGrb502Boston,MA02114-2620
M. Yashar S. Kalani, MDSt.Joseph’sHosp.&Med.Ctr.350WThomasRdPhoenix,AZ85013-4409
80
SECTION MEMBERSHIP ROSTER
John E. Kalsbeck, MDRileyHospitalForChildren702BarnhillDrIndianapolis,IN46202-5128
Paul M. Kanev, MDCtChildren’sMed.Ctr./Neurosurgery282WashingtonStHartford,CT06106-3322
Stuart S. Kaplan, MD3061SMarylandPkwySte200LasVegas,NV89109-6227
Ioannis Karampelas, MDCaseWesternReserveUniv.11100EuclidAveCleveland,OH44106-1716
Bruce A. Kaufman, MD999N92ndStMilwaukee,WI53226-4875
Christian Burnette Kaufman, MDPediatricNeurosurgeryAssoc.5455MeridianMarksRdNESte540Atlanta,GA30342-4723
Thomas Samuel Kaye, MD2MedicalCenterDrSte503Springfield,MA01107
Colin John Kazina, MDGB124820SherbrookSt.Winnipeg,MBR3A-1R9Canada
Robert F. Keating, MDChildren’sNationalMed.Ctr.111MichiganAveNWWashington,DC20010-2916
Brian Joseph Kelley, MDYale-NewHavenMc/NeurosurgeryPOBox208082NewHaven,CT06520-8082
Amy H. Kelly, CPNPCarolinaNeurosurgery&SpineAssoc.225BaldwinAveCharlotte,NC28204-3109
David L. Kelly Jr., MDMedicalCenterDr.WakeForestUniv./NeurosurgeryWinstonSalem,NC27157-0001
Tyler James Kenning, MDThomasJeffersonUniv.Hosp./Neurosurg.909WalnutSt2ndFloorPhiladelphia,PA19107-5211
Amir Kershenovich, MD100NAcademyAveDanville,PA17822-9800
John R. W. Kestle, MDPrimaryChildren’sMed.Ctr.100NMedicalDrSte1475SaltLakeCity,UT84113-1100
Erin Kiehna, MDSte305770BayStToronto,ONM5G-OA6Canada
David M. Klein, MD690FearringtonPostPittsboro,NC27312-8523
Laurence I. Kleiner, MDChildrensMedicalCenter1ChildrensPlzDayton,OH45404-1898
Paul Klimo Jr., MDSemmesMurpheyClinic6325HumphreysBlvdMemphis,TN38120-2300
Arnett Klugh, MDNavalMedicalCtr.SanDiegoDept.ofNeurosurgerySanDiego,CA92134-0001
David S. Knierim, MD751ForestAveSte202Zanesville,OH43701-2875
Edward J. Kosnik, MDColumbusChildren’sHospital700ChildrensDrColumbus,OH43205-2664
Karl F. Kothbauer, MDKantonsspitalLuzern/Div.ofNeurosurgeryDept.ofSurgeryLuzern,6000Switzerland
Maria Koutourousiou, MD200LothropStPUHB400Pittsburgh,PA15213-2536
Mark D. Krieger, MD1300NVermontAveSte1006LosAngeles,CA90027-6005
Abhaya Vivek Kulkarni, MD, FRCSHospitalforSickChildren/Neurosurgery1504555UniversityAve.Toronto,ONM5G-1X8Canada
Cornelius H. Lam, MDUniv.ofMinnesota420DelawareStSE/MCC96Minneapolis,MN55455-0341
Sandi K. Lam, MDUniversityofChicago5841SMarylandAveMc3026J341Chicago,IL60637-1447
John A. Lancon, MDSt.DominicNeurosurgeryAssociates969LakelandDrSte657Jackson,MS39216-4606
Sergey Nikolay Larionov, MDIrkutskChildHosp./NeurosurgicalDept.Gagarina4Irkutsk,664024RussianFederation
Jorge A. Lazareff, MDUCLA/NeurosurgeryBox957039LosAngeles,CA90095-0001
Mark Robert Lee, MD1301BarbaraJordanBlvdSte307Austin,TX78723-3080
Jeffrey R. Leonard, MDWashingtonUniversity/Neurosurgery660SEuclidAve#8057SaintLouis,MO63110-1010
Jessica Lessing, RN, CPNP317E34thStreetSuite1002NewYork,NY10065-7175
Michael Lee Levy, MD, PhD8010FrostStSte502SanDiego,CA92123-4222
Sean M. Lew, MDChildren’sHospitalofWisconsin999N92ndStSte310Milwaukee,WI53226-4875
Veetai Li, MD219BryantStBuffalo,NY14222-2006
David Delmar Limbrick, MD, PhD1ChildrensPl4S20SaintLouis,MO63110-1002
Julian J. Lin, MDUniv.ofIllinois/Neurosurgery719NWilliamKumpfBlvdPeoria,IL61605
81
SECTION MEMBERSHIP ROSTER
Benjamin C. Ling, MD105West8thAve.Ste.200Spokane,WA99204-2318
Kenneth I. Lipow, MDConnecticutNeurosurgicalSpecialists267GrantStBridgeport,CT06610-2805
Morris D. Loffman, MD17173StrawberryDrEncino,CA91436-3865
Gabriel M. Longo Calderon, MD7aCalle5-41/Zona4GuatemalaCity,01004Guatemala
Rafael Longo-Cordero, MDRochesterURBUniversityGDNS911CalleSanJuan,PR00927-4812
Ralph C. Loomis, MDMountainNeurosurgical&SpineCtr.7VanderbiltParkDrAsheville,NC28803-1700
Kenneth M. Louis, MD3000EFletcherAveSte340Tampa,FL33613-4645
Mark G. Luciano, MD, PhDClevelandClinicFoundation9500EuclidAve.S60Cleveland,OH44195-0001
Thomas G. Luerssen, MDClinicalCareCenter6621FanninStCCC1230.10Houston,TX77030-2303
Joseph R. Madsen, MDBrigham&Women’sHosp.300LongwoodAveRm312Boston,MA02115-5724
Suresh N. Magge, MDChildren’sNtl.Med.Ctr.Neurosurgery111MichiganAve.NW4thFlr.Ste.100Washington,DC20010
Gail A. Magid, MDPOBox66Wilson,WY83014-0066
Gary Magram, MDChildren’sHosp./Neurosurgery9300ValleyChildrensPlMadera,CA93636-8761
Cormac O. Maher, MDUniv.ofMichigan1500E.MedicalCenterDr./3552TaubmanCtr.AnnArbor,MI48109
Kim Herbert Manwaring, MD
Timothy B. Mapstone, MDUniv.ofOklahomaHSC/Neurosurgery1000NLincolnBlvdSte400OklahomaCity,OK73104-3252
Arthur E. Marlin, MD2TampaGeneralCirFl7Tampa,FL33606-3603
Jonathan E. Martin, MDConnecticutChildren’sMc/Neurosurgery282WashingtonStHartford,CT06106-3322
Timothy Yefim Maryanov, MDUniv.ofSouthCarolina/Neurosurgery3RichlandMedicalParkSte310Columbia,SC29203-6862
Gary W. Mathern, MDUniversityofCaliforniaLosAngeles710WestwoodPlaza/NeurosurgeryLosAngeles,CA90095-0001
Todd A. Maugans, MD3333BurnetAveMCC2016Cincinnati,OH45229-3026
John R. Mawk, MD, JD788AshlandAveSaintPaul,MN55104-7119
Catherine Anne Mazzola, MDAtlanticNeurosurgicalSpecialists131MadisonAveSte140Morristown,NJ07960-7360
James P. (Pat) McAllister II, PhDDept.ofNeurosurgery175N.MedicalDr.E.SaltLakeCity,UT84132-0001
David McAuley, MDMillCottage10MillRd./BallyknockanNewtownards,BT236NGUnitedKingdom
Jack E. McCallum, MDSouthwestNeurologicalSurgery8008thAveSte306FortWorth,TX76104-2602
J. Gordon McComb, MDUniv.ChildrensMed.Group1300NVermontAve#1006LosAngeles,CA90027-6005
Edison P. McDaniels II, MDGundersen-LutheranHealthSciences1900SouthAveEb36LaCrosse,WI54601-5467
C. Scott McLanahan, MDCarolinaNeurosurgery&SpineAssoc.225BaldwinAveCharlotte,NC28204-3109
Robert L. McLaurin, MD, JDSte.900Fourth&VineTowerCincinnati,OH45202
David Gordon McLone, MD, PhDChildren’sMemorialHospital2300Children’sPlazaSte.28Chicago,IL60614
Sean A. McNatt, MD1600EurekaRdMobIIRoseville,CA95661-3027
P. Daniel McNeely, MDPOBox97005850UniversityAve.Halifax,NSB3K6R8Canada
John Mealey Jr., MD9315SpringForestDrIndianapolis,IN46260-1269
Michael Dean Medlock, MD4CentennialDrSte204Peabody,MA01960-7930
Joshua Eric Medow, MDUniversityofWisconsin-Madison600HighlandAve./NeurosurgeryMadison,WI53792-0001
Hatem Salah Megahed, MD4410MedicalDrSte540SanAntonio,TX78229-3755
Vivek Mehta, MD, MScUniv.ofAlberta/Neurosurgery8440-112St./2D1.02MacKenzieHSCEdmonton,ABT6E-6S8Canada
Hal S. Meltzer, MD8010FrostStSte502SanDiego,CA92123-4222
82
SECTION MEMBERSHIP ROSTER
Arnold H. Menezes, MDUniversityofIowaHospitals200HawkinsDrIowaCity,IA52242-1007
W. Jost Michelsen, MD3229SEBraemarWayPortStLucie,FL34952-6035
Thomas H. Milhorat, MDNorthShoreUniversityHospital300CommunityDrManhasset,NY11030-3816
John I. Miller, MDLongIslandCollegeHosp.339HicksStSte1110Brooklyn,NY11201-5509
Sanjay N. Misra, MDPOBox1129Frisco,CO80443-1129
Mark A. Mittler, MDLongIslandNeurosurgicalAssociates410LakevilleRdSte204NewHydePark,NY11042-1103
Avinash Lalith Mohan, MDNewYorkMedicalCollegeMungerPavillionRm.3293rdFl.Valhalla,NY10595
Aaron Mohanty, MD4923WilliamsCourtLnHouston,TX77081-2103
Richard H. Moiel, MDPOBox22634Houston,TX77227-2634
Leon E. Moores, MDWalterReedArmyMed.Ctr.NeurosurgeryServiceWashington,DC20307
Thomas M. Moriarty, MD, PhD210EGrayStSte1102Louisville,KY40202-3907
Michon Morita, MD1380LusitanaStSte712Honolulu,HI96813-2443
Nobuhito Morota, MDNeurosurgery/NCCHD2-10-1Ohkura/SetagayaTokyo,1578535Japan
William Joseph Morris, MD9156thAveSte2Tacoma,WA98405-4682
Glenn Morrison, MD3215S.W.62ndAve.Miami,FL33155
Luis Rafael Moscote-Salazar, MDCarrera45ANumero134A-40#301Bogota,Colombia
S. David Moss, MDCardonChildren’sHospital1432SDobsonRdSte403Mesa,AZ85202-4777
Carrie Rebecca Muh, MD3712DoverRdDurham,NC27707-5106
Michael S. Muhlbauer, MDSemmesMurpheyClinic6325HumphreysBlvdMemphis,TN38120-2300
Michael G. Muhonen, MD1010W.LaVetaAve.Ste.710Orange,CA92868-4306
Lorenzo F. Munoz, MD1725WHarrisonStSte970Chicago,IL60612-3828
Karin M. Muraszko, MD1500EMedicalCenterDr3470TC/NeurosurgeryAnnArbor,MI48109-5000
John S. Myseros, MDChildren’sNationalMed.Ctr.111MichiganAveNWWashington,DC20010-2916
Joseph M. Nadell, MD2920CampStNewOrleans,LA70115-2204
Mahmoud G. Nagib, MD800E28thSt305PiperBldg.Minneapolis,MN55407-3723
Prithvi Narayan, MD3601AStPhiladelphia,PA19134-1043
Nikhil Nayak, MDUniv.ofPennsylvania/Neurosurgery3400SpruceSt3rdFlPhiladelphia,PA19104-4206
Tien Trong Nguyen, MD11190WarnerAveSte305FountainValley,CA92708-4047
Michael F. Nido, PA-CCarolinaNeurosurgery&SpineAssoc.225BaldwinAveCharlotte,NC28204-3109
Dimitrios C. Nikas, MD1847NDaytonStChicago,IL60614-5002
W. Jerry Oakes, MDChildren’sHospitalOfAlabama16007thAveSAcc400Birmingham,AL35233-1711
Mark Stephen O’Brien, MDArkansasChildren’sHospital800MarshallStLot838LittleRock,AR72202-3510
Eylem Ocal, MDSlot8381Children’sWayLittleRock,AR72202
Jeffrey G. Ojemann, MDChildren’sHosp.&RegionalMed.4800SandPointWayNE#W-7729Seattle,WA98105-3901
Greg Olavarria, MDPediatricNeurosurgery83ColumbiaStOrlando,FL32806-1101
Brent Randle O’Neill, MD13123E16thAveB330Aurora,CO80045-7106
Kaine Chamberlain Onwuzulike, MD, PhDCaseWesternReserveUniv.11100EuclidAveCleveland,OH44106-1716
Renatta J. Osterdock, MD1601E19thAveSte5125Denver,CO80218-1216
Larry Keith Page, MD13845SW73rdCtPalmettoBay,FL33158-1213
Dachling Pang, MDKaiserPermanenteHospital280WMacarthurBlvdOakland,CA94611-5642
Andrew D. Parent, MDUniv.ofMississippiMedicalCtr.2500NStateStJackson,MS39216-4500
83
SECTION MEMBERSHIP ROSTER
Tae Sung Park, MDSt.LouisChildren’sHospital1ChildrensPlSte4S20SaintLouis,MO63110-1002
Michael David Partington, MDGilletteChildren’sSpecialtyHealthcare200UniversityAveESaintPaul,MN55101-2507
Jogi Venkata Pattisapu, MD80BonnieLochCtOrlando,FL32806-2908
Jerry O. Penix, MDChildren’sSurgicalSpecialtyGroup601ChildrensLnSte5ANorfolk,VA23507-1910
Joseph H. Piatt Jr., MD251LindenLnMerionStation,PA19066-1711
Prem K. Pillay, MBBSAsianBrain-Spine-NerveCenter3Mt.Elizabeth#15-03Singapore,228510Singapore
David W. Pincus, MD, PhDUniv.ofFlorida-GainesvilleBox100265Gainesville,FL32610
Thomas Pittman, MDUniv.ofKentuckyMed.Ctr.800RoseSt.Rm.MS05-ALexington,KY40536-0001
Ian F. Pollack, MDChildren’sHospitalofPittsburgh4401PennAvePittsburgh,PA15224-1334
Harold D. Portnoy, MD18530CypressHavenDr.Ft.Myers,FL33908
Alexander F. Post, MDNJPediatricNeurosurgicalAssoc.131MadisonAve.Ste.140Morristown,NJ07960
Mark R. Proctor, MDChildrensHospital300LongwoodAveHunnewell2Boston,MA02115-5724
Mark J. Puccioni, MDMidwestNeurosurgery8005FarnamDrSte305Omaha,NE68114-3426
Patricia B. Quebada-Clerkin, MD9300ValleyChildrensPlMadera,CA93636-8761
Joseph V. Queenan, MDHahnemannUniv.Hosp./Neurosurgery245N15thStMS409Philadelphia,PA19102-1101
Taopheeq Bamidele Rabiu, MDDivisionofNeurologicalSurgeryDepartmentofSurgeryIdo-Ekiti,372001Nigeria
Corey Raffel, MD, PhD400W12thAveWisemanHall385WisemanHall385Columbus,OH43210-2207
John Ragheb, MDAmbulatoryCareBldg./Ped.Neuros.3215S.W.62ndAve.Ste.3109Miami,FL33155
Nathan Joseph Ranalli, MDSt.LouisChildren’sHospital1ChildrensPlSte4S20StLouis,MO63110-1002
Mahmoud Rashidi, MD4HawthorneDrBedford,NH03110-6983
Donald H. Reigel, MD134ShenotRdWexford,PA15090-7455
Harold Louis Rekate, MD865NorthernBlvdGreatNeck,NY11021-5335
Ann M. Ritter, MDVirginiaCommonwealthUniversityPOBox980631Richmond,VA23298-0631
Jay K. Riva-Cambrin, MD100MarioCapecchiDr.Ste.1475SaltLakeCity,UT84113-1103
Elias B. Rizk, MD517NorthstarDrHarrisburg,PA17112-8963
Shenandoah Robinson, MDChildren’sHospitalBoston300LongwoodAveHunnewell2Boston,MA02115-5724
Walker L. Robinson, MDCarleClinic&FoundationHosp.602WUniversityAveUrbana,IL61801-2530
Brandon Rocque, MDDept.ofNeurosurgery600HighlandAve.Rm.K4/822Madison,WI53792-0001
Luis Alberto Rodriguez, MDMemorialHealthcare1150N35thAveSte300Hollywood,FL33021-5428
Luis F. Rodriguez, MDAllChildren’sHospital6015thSt.Ste.511St.Petersburg,FL33701
Bruce R. Rosenblum, MD160AvenueattheCMN/Ste2Shrewsbury,NJ07702-4570
Alan D. Rosenthal, MD7840TalaveraPlDelrayBeach,FL33446-4321
Allen S. Rothman, MD421HuguenotStSte36NewRochelle,NY10801-7021
Curtis J. Rozzelle, MD16007thAveSACC400Birmingham,AL35233-1711
John R. Ruge, MD1875DempsterStSte605ParkRidge,IL60068-1168
James T. Rutka, MD, PhDHospitalforSickChildren555UniversityAve.#1503Toronto,ONM5G-1X8Canada
Petr O. Ruzicka, MDBannerChildren’sHosp/PediatricNeurosurgery1432SDobsonRdSte304Mesa,AZ85202-4773
David I. Sandberg, MDSte.31093215S.W.62ndAve.Miami,FL33155
Adam Lance Sandler, MDMontefioreMed.Ctr./Neurosurgery111E210thStBronx,NY10467-2401
84
SECTION MEMBERSHIP ROSTER
Amanda Muhs Saratsis, MD1320NVeitchStUnit1533Arlington,VA22201-6218
Osamu Sato, MD#404CeleasActia2-13-6UtuskushigaokaAobaYokohama,225-0002Japan
Steven J. Schiff, MD, PhDPennsylvaniaStateUniv.212Earth-EngineeringSci.Bldg.UniversityPark,PA16802
Steven J. Schneider, MDLongIslandNeurosurgicalAssociates410LakevilleRdSte204NewHydePark,NY11042-1103
Luis Schut, MD
Lauren F. Schwartz, MD131MadisonAveSte140Morristown,NJ07960-7360
R. Michael Scott, MDTheChildren’sHosp.Boston300LongwoodAveHunnewell2Boston,MA02115-5724
Mehmet Selcuki, MD, PhDCBUniv.Sch.ofMed./Neurosurgery1403sk5/8AlsancakIzmir,35220Turkey
Nathan R. Selden, MD, PhDOregonHealth&Sci.UniversityCH8NPortland,OR97239-4501
Wan Tew Seow, MDKKWomen’s&Children’sHospital100BukitTimahRd.Singapore,229899Singapore
Thomas J. Sernas, PA-C, MS131MadisonAve.Ste140Morristown,NJ07960
David H. Shafron, MDDept.ofNeurosurgery1919EThomasRdPhoenix,AZ85016-7710
Ronald F. Shallat, MD400ParnassusAveRmA-808SanFrancisco,CA94143-2202
Howard J. Silberstein, MD1445PortlandAveSte305Rochester,NY14621-3044
James C. Simmons, MD177NHighlandStApt4209Memphis,TN38111-4777
Gary Robert Simonds, MDCarilionNeurosurgicalCare3RiversideCirRoanoke,VA24016-4955
Robert J. Singer, MDVanderbuiltUniv.Med.Ctr.116121stAve.S.T-4224MCNNashville,TN37232
Ashutosh Singhal, MDDept.ofNeurosurgeryK3-1594480OakSt.Vancouver,BCV6H-3V4Canada
Stanley O. Skarli, MD414PlymouthAveNEOfcGrandRapids,MI49505-6038
Frederick H. Sklar, MDNeurosurgeonsForChildren1935MedicalDistrictDrDallas,TX75235-7701
Lenwood P. Smith Jr., MDUniversitySpecialtyClinics3MedicalParkRd.Ste.310Columbia,SC29203
Jodi L. Smith, MD, PhD702BarnhillDrSte1134Indianapolis,IN46202-5128
Edward Robert Smith, MDChildren’sHospitalBoston/Neurosurgery300LongwoodAveBoston,MA02115-5724
Harold P. Smith, MD
Matthew D. Smyth, MDSt.LouisChildren’sHospital1ChildrensPlSaintLouis,MO63110-1002
Debbie K. Song, MDGilletteChildren’sSpecialtyHealthcare200UniversityAveESaintPaul,MN55101-2507
Sandeep Sood, MDPediatricNeurosurgeryGroupPc3901BeaubienStFl2Detroit,MI48201-2119
Ivan Javier Sosa, MD, FAANS79CalleVeredaUrbMonteVerdeRealSanJuan,PR00926-6054
Jenny Dawn Souster, MD2842HollyridgeDrLosAngeles,CA90068-2321
Mark M. Souweidane, MDDept.NeurologicalSurgery525E68thSt#99NewYork,NY10065-4870
Heather Stevens Spader, MDBrownMed.Sch./Neurosurgery593EddySt.,APC6Providence,RI02903
Theodore James Spinks, MD4500WilliamsDr.Suite212,#341Austin,TX78633
Sherman Charles Stein, MD310SpruceStPhiladelphia,PA19106-4201
Paul Steinbok, MDBritishColumbiaChildren’sHosp.4480OakSt.Rm.K3-159Vancouver,BCV6H-3V4Canada
Thomas C. Steineke, MD, PhDNewJerseyNeuroscienceInst.65JamesStEdison,NJ08820-3947
Charles B. Stevenson, MD3333BurnetAveML2016Cincinnati,OH45229-3026
Scellig Stone, MDTorontoWesternHospitalWW4-450399BathurstSt.Toronto,ONM5T-2S8Canada
Bruce B. Storrs, MD138DiamondTailRdPlacitas,NM87043-8338
Timothy Alexander Strait, MDNeurosurgicalGroupofChattanooga1010E3rdStSte202Chattanooga,TN37403-2174
Douglas L. Stringer, MD2011HarrisonAvePanamaCity,FL32405-4545
Merle Preston Stringer, MD2011HarrisonAvePanamaCity,FL32405-4545
85
SECTION MEMBERSHIP ROSTER
Peter P. Sun, MDChildren’sHospitalofOakland74452ndStOakland,CA94609-1810
Leslie N. Sutton, MDChildren’sHospitalofPhiladelphia34th&CivicCenterBlvd.Philadelphia,PA19104
Dale M. Swift, MDNeurosurgeonsforChildren1935MotorStFl3Dallas,TX75235-7794
Michael S. Taekman, MD15OakmontCtSanRafael,CA94901-1235
Muhammad Zubair Tahir, MDAgaKhanUniv.Hosp./NeurosurgeryStadiumRd.Karachi,Pakistan
Mandeep Singh Tamber, MD, PhDChildren’sHosp.ofPittsburgh4401PennAveFl4Pittsburgh,PA15224-1334
Izabela Tarasiewicz, MDConnecticutChildrensHosp.Dept.Neurosurgery282WashingtonSt.Hartford,CT06106
Kimberly D. Terry, MD315NSanSabaSte1210SanAntonio,TX78207-3123
Willard D. Thompson Jr., MDNeurologicalInst.ofSavannah4EJacksonBlvdSavannah,GA31405-5810
Eric Michael Thompson, MDOregonHlth.&Sci.Univ./Neurosurgery3303SWBondAve#Ch8NPortland,OR97239-4501
Ashley Grosvenor Tian, MDStanfordUniv./Neurosurgery300PasteurDrRmR281Stanford,CA94305-2200
Michael E. Tobias, MDNewYorkMedicalCollegeMungerPavillionValhalla,NY10595
Tadanori Tomita, MDChildren’sMemorialHospital2300Children’sPlazaSte.28Chicago,IL60614
Zulma Sarah Tovar-Spinoza, MDSunyUpstateMed.Univ.750EAdamsStSyracuse,NY13210-2342
Eric R. Trumble, MD615EPrincetonStSte540Orlando,FL32803-1424
Gerald F. Tuite Jr., MD6015thStSSte511SaintPetersburg,FL33701-4804
Noel Tulipan, MD9226Dot2200Children’sWayNashville,TN37232-0001
Michael S. Turner, MDIndianapolisNeurosurgicalGroup1801SenateBlvdSte610Indianapolis,IN46202-1259
Rachana Tyagi, MD125PatersonSt#2100NewBrunswick,NJ08901-1962
Gary William Tye, MDNeurosurgery/McVCampus417N11thStFl6Richmond,VA23298-5002
Elizabeth C. Tyler-Kabara, MD, PhDChildren’sHosp.ofPittsburgh4401PennAvePittsburgh,PA15224-1334
David D. Udehn, MD800CooperAveSte8Saginaw,MI48602-5373
Ronald H. Uscinski, MD5530WisconsinAveSte1147ChevyChase,MD20815-4330
Shobhan H. Vachhrajani, MDHosp.forSickChildren555UniversityAve.Ste.1503Toronto,ONM5G1X8Canada
Payman Vahedi, MDTabrizUniv.ofMed.Sci.ImamRezaHosp./GolgashtSt.Tabriz,5166614756Iran(IslamicRepublicof)
Adan Agreda Vasquez, MDDr.Jimenez340Col.DoctoresCuauhtemoc,BCN06720Mexico
Michael Vassilyadi, MDChildren’sHospitalEastOntario401SmythRd.Ottawa,ONK1H8L1Canada
Dominic Venne, MD, MScShaikhKhalifaMedicalCityPOBox51900AbuDhabi,UnitedArabEmirates
Enrique C. Ventureyra, MDChildren’sHospitalEastOntario401SmythRd.Ottawa,ONK1H-8L1Canada
Sandya Venugopal, MDApt23311AbellAveBaltimore,MD21218-2854
John Kenric Vries, MDUniv.ofPittsburghMed.Ctr./MedicalArchivalSystems1370BeulahRdBldg5Pittsburgh,PA15235-5068
Margaret Rose Wacker, MD603HarpPlRedlands,CA92373-5664
Brian P. Walcott, MDMassachusettsGen.Hosp./Neurosurgery55FruitSt#Wh502Boston,MA02114-2621
Steven L. Wald, MD469WhiteHorseTrlPalmDesert,CA92211-8947
John B. Waldman, MDAlbanyMedicalCenter47NewScotlandAve.MC-10Albany,NY12208
Marion L. Walker, MDPrimaryChildren’sMed.Ctr.100MarioCapecchiDr#1475SaltLakeCity,UT84113-1103
John Willson Walsh, MD, PhDTulaneUniv.Sch.ofMed.1430TulaneAve#Sl47NewOrleans,LA70112-2632
Kyu-Chang Wang, MD, PhDDiv.ofPediatricNeurosurgery101Daehang-no/Jongno-guSeoul,110744RepublicofKorea
86
SECTION MEMBERSHIP ROSTER
John D. Ward, MDMedicalCollegeofVirginiaPOBox980631Richmond,VA23298-0631
Daryl E. Warder, MD, PhDBronsonNeurologicalServices601JohnStSteM-124Kalamazoo,MI49007-5377
Monica C. Wehby, MDLegacyEmanuelHospital501NGrahamStSte315Portland,OR97227-1655
Howard L. Weiner, MDNewYorkUniversityMed.Ctr.317E34thSt#1002NewYork,NY10016-4974
Martin H. Weiss, MDLAC-USCMedicalCenter1200NStateStSte5045LosAngeles,CA90033-1029
John C. Wellons III, MDChildren’sHosp.ofAlabama16007thAveSACC400Birmingham,AL35233-1711
Bradley E. Weprin, MDNeurosurgeonsForChildren1935MotorStFl3Dallas,TX75235-7794
Nicholas M. Wetjen, MDGonda8200FirstSt.S.W.Rochester,MN55905-0001
William E. Whitehead, MD, MPHPediatricNeurosurgery6621FanninSt#CC1230.01Houston,TX77030-2303
Jean K. Wickersham, MD1535VirginiaWayLaJolla,CA92037-3836
James T. Wilson, MDMaineMedicalPartners49SpringStScarborough,ME04074-8926
Ronald J. Wilson, MDAustinBrain&Spine801W38thStSte400Austin,TX78705-1103
Joel W. Winer, MDWellspanNeurosurgery228SaintCharlesWayYork,PA17402-4644
Ken Rose Winston II, MDTheChildren’sHospital13123E16thAveAurora,CO80045-7106
Jeffrey H. Wisoff, MD317E34thStSte1002NewYork,NY10016-4974
Daniel Won, MD112721stStUnit2SantaMonica,CA90403-5624
Meredith V. Woodward, MDValleyChildren’sHospital9300ValleyChildren’sPl.Madera,CA93638
David Michael Wrubel, MD5455MeridianMarksRdNESte540Atlanta,GA30342-4723
Shokei Yamada, MD5410ViaSanJacintoRiverside,CA92506-3647
Esmiralda Yeremeyeva, MD410W10thAveColumbus,OH43210-1240
Juneyoung Yi, MD750EAdamsStSyracuse,NY13210-2342
Karol Zakalik, MDWilliamBeaumontHospital3535W13MileRdSte636RoyalOak,MI48073-6770
Ahmad Zakeri, MD4235SecorRdToledo,OH43623-4231
Edward J. Zampella, MDAtlanticNeurosurgicalSpecialists310MadisonAveSte200Morristown,NJ07960-6967
Boris Zivny, MDNeuroCentrumClinicRicanska1177JeseniceuPrahy,CZ-25242CzechRepublic
Alexander Zouros, MDLLUMC/Neurosugery11234AndersonStRm2562BLomaLinda,CA92354-2804
John G. Zovickian, MDPermanteMed.Group/Ped.Neuros.280WMacarthurBlvdOakland,CA94611-5642
Marike Zwienenberg-Lee, MDDept.ofNeurosurgery4860YStSte3740Sacramento,CA95817-2307
42nd Annual Meeting of the AANS/CNS Section on Pediatric Neurological Surgery
December3–December6,2013WestinHarbourCastleToronto,ON,Canada
SAVE THE DATE
JointlysponsoredbytheAANS
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