Journal Of Neurosurgery. Pediatrics[JOURNAL]
Sun
200 papers
Comparison of outcomes after occipitocervical fusion in adult versus pediatric patients: the University of Oklahoma experience.
Patel P, Jea M, Jea A
J Neurosurg Pediatr · 2026 Jun · PMID 42361376 · Publisher ↗
OBJECTIVE: Occipitocervical fusion (OCF) is a well-established technique for stabilizing the craniovertebral junction in cases of trauma, congenital malformation, degenerative changes, infection, or neoplasm. Although nu...
OBJECTIVE: Occipitocervical fusion (OCF) is a well-established technique for stabilizing the craniovertebral junction in cases of trauma, congenital malformation, degenerative changes, infection, or neoplasm. Although numerous studies have evaluated outcomes in isolated adult or pediatric cohorts, no direct comparisons between these populations have been published. The authors hypothesized that OCF is better tolerated in pediatric patients, with lower complication rates and superior functional recovery. METHODS: A retrospective analysis of patients who underwent OCF between March 2021 and August 2023 at a single institution was conducted. Patients with ≥ 6 months' follow-up or those who died within 6 months of surgery were included in the analysis. The patients' clinical symptoms, radiographic fusions, complication rates, and responses to the 3-item Occipitocervical Fusion Outcomes Survey (OFOS-3) were assessed. The OFOS-3 is a novel, 3-question, patient- or parent-reported outcomes tool for evaluating pain, function, and head and neck mobility. RESULTS: Twenty-four patients, 11 adult and 13 pediatric, were included in this study. The mean follow-up for the patients who survived at least 6 months after surgery was 30 months (range 7-51 months). Fusion levels most commonly ranged from the occiput to C4 in adult patients and the occiput to C2 in pediatric patients, with screw lengths ranging from 6 to 24 mm and screw diameters ranging from 3.0 to 4.5 mm. Adult patients demonstrated a higher complication rate (27.3%) than pediatric patients (0%); however, complication rates were not significantly different between the two. In comparing adult and pediatric patients, the OFOS-3 overall scores were statistically different (p = 0.037), but the OFOS-3 component scores were not. CT-proven fusion was achieved in all patients who had ≥ 6 months' follow-up. There were no significant differences in non-age-related demographics (sex, indication for surgery, American Society of Anesthesiologists status), procedure-related factors (operative time, estimated blood loss, size of spinal instrumentation), and outcomes (length of stay, intensive care unit placement, OFOS-3 scores). CONCLUSIONS: OCF appears to be safe and effective in both adult and pediatric populations, with similar surgical and functional outcomes observed. The OFOS-3 may be more sensitive at revealing clinical differences than the individual measures of pain, function, and head and neck mobility. Further prospective studies are warranted to validate the comparative findings between adult and pediatric patients, as well as the OFOS-3 instrument.
A nomogram predicting postoperative recurrence risk in SF1/TPIT nonfunctioning pituitary neuroendocrine tumors: integration of tumor heterogeneity quantification on T2-weighted imaging.
Zhang Z, Yin J, Hu M … +6 more , He J, Hu Y, Yang X, Yi Z, Li P, Liu P
J Neurosurg · 2026 Jun · PMID 42361371 · Publisher ↗
OBJECTIVE: Nonfunctioning pituitary neuroendocrine tumors (NF-PitNETs) can recur despite gross-total resection (GTR), and the accurate prediction of tumor recurrence remains a major clinical challenge. In this study, aut...
OBJECTIVE: Nonfunctioning pituitary neuroendocrine tumors (NF-PitNETs) can recur despite gross-total resection (GTR), and the accurate prediction of tumor recurrence remains a major clinical challenge. In this study, authors aimed to evaluate the predictive value of the T2-weighted signal coefficient of variation (T2-CV) and develop an integrated prognostic nomogram for recurrence-free survival (RFS) in NF-PitNET. METHODS: Tumor heterogeneity was assessed using T2-weighted MRI. Clinical, radiological, and pathological variables were retrospectively collected on patients with a PitNET diagnosis between 2011 and 2024. Kaplan-Meier analysis was used for survival assessment of each parameter. A multivariate Cox proportional hazards model was employed to identify independent predictors of RFS, and a prognostic nomogram was subsequently developed based on these significant factors. The total score derived from the nomogram was used to stratify patients into distinct risk groups. RESULTS: This study included 596 patients with NF-PitNET who underwent GTR. Multivariate analysis identified four independent factors associated with shorter RFS: age < 41 years, Knosp grade 3-4, T2-CV ≥ 0.442, and Ki-67 index ≥ 3% (all p < 0.001). A nomogram incorporating these variables was developed and demonstrated superior predictive accuracy (area under the curve [AUC] = 0.801) compared to any single predictor alone (p < 0.001). The nomogram achieved a concordance index of 0.82, demonstrating good calibration and strong clinical applicability. Its time-dependent receiver operating characteristic analysis further demonstrated AUC values of 0.85, 0.89, 0.84, 0.86, and 0.82 at 12, 24, 36, 48, and 60 months, respectively, indicating particular strength in short-term recurrence prediction. Furthermore, applying a cutoff score of 72.41, the nomogram effectively stratified patients into high- and low-risk groups, which were differentiated by significantly different median RFS (81.17 vs 99.93 months, respectively, HR 7.364, 95% CI 4.375-12.393, p < 0.001). CONCLUSIONS: T2-CV, a novel quantitative MRI parameter, serves as an independent predictor of RFS in patients following GTR of NF-PitNET. A nomogram integrating T2-CV with other key prognostic factors demonstrated high accuracy in identifying high-risk individuals.
Resection plus stereotactic radiosurgery versus stereotactic radiosurgery alone and control of brain metastasis-induced seizures.
Wang SY, Bowden SG, Reiner AS … +10 more , Toth AJ, Wierzbicki M, Tabar V, Brennan CW, Yu KKH, Bou Nassif R, Imber BS, Pike LRG, Wilcox JA, Moss NS
J Neurosurg · 2026 Jun · PMID 42361368 · Publisher ↗
OBJECTIVE: Seizures cause significant morbidity in patients with brain metastasis (BrM). Local therapies for BrM, including resection with adjuvant stereotactic radiosurgery and stereotactic radiosurgery (SRS) alone, hav...
OBJECTIVE: Seizures cause significant morbidity in patients with brain metastasis (BrM). Local therapies for BrM, including resection with adjuvant stereotactic radiosurgery and stereotactic radiosurgery (SRS) alone, have undefined seizure outcomes. The authors sought to compare seizure control in patients with BrM-induced seizures treated with either modality. METHODS: Patients who received resection surgery plus adjuvant SRS (S+SRS) or SRS for BrM at a National Cancer Institute (NCI)-designated Comprehensive Cancer Center between January 2015 and December 2023 were retrospectively reviewed. Patients with pretreatment seizure and semiology attributable to an untreated metastasis were included. The cumulative incidence rates of first posttreatment seizure were estimated for both treatment groups. Multivariable analyses identified risk of posttreatment seizure under subdistribution hazards modeling in the competing risk setting to account for death. The authors secondarily assessed overall survival (OS) and local and distal progression rates between treatments. RESULTS: Two hundred fifty-five of 5284 patients treated for BrM had pretreatment seizures, and 190 patients met the inclusion criteria: 76 (40%) treated with S+SRS and 114 (60%) treated with SRS. One hundred eighty-five (97.4%) patients were taking an antiseizure medication at the end of treatment. The 6-month rate (95% CI) of seizure freedom was 86.71% (77.97%-93.23%) for patients treated with S+SRS and 69.18% (60.54%-77.46%) for patients treated with SRS (p = 0.003). The 12-month rates of seizure freedom were 74.40% (64.01%-83.74%) and 65.59% (56.80%-74.24%) for the S+SRS and SRS groups, respectively (p = 0.091). In the multivariable models, S+SRS was associated with 56% and 27% reductions in seizure risk relative to SRS at 6 and 12 months, respectively, though this was only statistically significant at 6 months. Median OS (95% CI) was 2.62 (1.52-6.52) years for S+SRS patients and 0.83 (0.62-1.54) years for SRS patients (p < 0.001). Treatments did not differ in terms of the rates of local failure (p = 0.52) or distal intracranial progression (p = 0.26) among patients with radiographic follow-up. In subgroups stratified by maximum tumor diameter, patients treated with S+SRS had a lower 6-month cumulative incidence rate of recurrent seizure than patients treated with SRS, though this was only statistically significant for patients with tumors > 3 cm. CONCLUSIONS: Patients treated with S+SRS experienced fewer posttreatment seizures at 6 months than patients treated with SRS, despite larger index lesions in patients treated with S+SRS and prevalent antiseizure medication use in the entire study population. Although multivariable models showed no significant associations at 12 months or beyond, the role of resection in controlling BrM-induced seizures warrants further investigation.
Predictors of ventricular shunt survival in neoplastic hydrocephalus: a retrospective cohort study of 239 patients.
Grin EA, Kelleher AC, de Souza DN … +7 more , Palla A, Gajic ZZ, Eremiev AN, Dastagirzada YM, Wisoff JH, Hidalgo ET, Harter DH
J Neurosurg · 2026 Jun · PMID 42361367 · Publisher ↗
OBJECTIVE: Hydrocephalus secondary to CNS tumors is common and carries high shunt failure rates, yet predictors of shunt survival remain poorly defined. The aim of this study was to identify patient-, tumor-, and treatme...
OBJECTIVE: Hydrocephalus secondary to CNS tumors is common and carries high shunt failure rates, yet predictors of shunt survival remain poorly defined. The aim of this study was to identify patient-, tumor-, and treatment-related predictors of shunt outcomes in neoplastic hydrocephalus. METHODS: This retrospective single-institution analysis included consecutive patients who underwent ventriculoperitoneal or ventriculoatrial shunt placement for neoplastic hydrocephalus between February 2013 and February 2024. Patients were identified using validated natural language processing and manual review. Demographic, oncological, and surgical variables, including tumor location, neurological symptoms, and resection history, were analyzed. The primary outcome was shunt revision for any cause at 1, 3, and 5 years. Fisher's exact test or the chi-square test was used for categorical comparisons. Kaplan-Meier and log-rank analyses were used to assess shunt survival, with subgroup analysis for age and etiology. RESULTS: Overall, 239 patients (140 female, median age 53 years) were included, with 186 adults and 53 pediatric patients. Intraventricular tumor location showed the strongest association with shunt failure across all time points (5-year OR 4.39, p < 0.001). Preoperative neurological symptoms (seizures and visual/auditory deficits) were associated with higher odds of single and multiple shunt revisions (OR range 1.92-2.15, p ≤ 0.03). WHO grade 2 tumors trended toward greater late (5-year) failure risk (OR 2.8, p = 0.06). Obstruction accounted for 35.6% of shunt failures, followed by infection. Adjuvant chemotherapy and radiation therapy were not associated with shunt failure after adjustment for survival differences. CONCLUSIONS: In this largest-to-date cohort of patients who underwent shunt placement for neoplastic hydrocephalus, the factors associated with shunt failure were intraventricular tumor location, multiple resections, and preoperative neurological symptoms. Adjuvant therapies had minimal impact. These findings support individualized risk stratification and targeted follow-up and provide a foundation for targeted prospective studies.
Editorial. Training pediatric neurosurgeons: but where in the world do they go?
Ahn ES
J Neurosurg Pediatr · 2026 Jun · PMID 42361365 · Publisher ↗
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Prognostic scores in pediatric gunshot-induced traumatic brain injury: comparative analysis.
Trivedi JC, Mulugeta MG, Baer AV … +4 more , Lepard J, Chern JJ, Reisner A, Blackwell LS
J Neurosurg Pediatr · 2026 Jun · PMID 42361363 · Publisher ↗
OBJECTIVE: The aim of this study was to compare the prognostic performance of the Baylor, St. Louis, and Surviving Penetrating Injury to the Brain (SPIN) scoring systems for mortality and neurosurgical intervention in ch...
OBJECTIVE: The aim of this study was to compare the prognostic performance of the Baylor, St. Louis, and Surviving Penetrating Injury to the Brain (SPIN) scoring systems for mortality and neurosurgical intervention in children with gunshot-induced traumatic brain injury (GTBI), clarifying how their differing variable compositions influence accuracy and clinical applicability in pediatric GTBI. METHODS: This was a retrospective cohort study of pediatric patients with firearm-related intracranial injuries presenting to a tertiary pediatric trauma center from January 2014 to April 2023. Clinical, laboratory, and neuroimaging variables were abstracted to calculate Baylor, St. Louis, and SPIN scores. Primary outcomes were mortality and neurosurgical intervention (external ventricular drain [EVD] placement, intracranial pressure [ICP] monitor placement, craniotomy, decompressive hemicraniectomy [DHC]). Associations were assessed with univariate and multivariate logistic regressions (α = 0.05). Discrimination was evaluated with receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC). Optimal score cut points were derived for clinical utility, and confusion matrix metrics summarized performance. Clinical utility was assessed quantitatively by statistical performance and qualitatively by considering input availability (e.g., CT dependence), motivating a pragmatic, two-step workflow. RESULTS: Eighty-two children (mean age 8.59 ± 4.73 years) met inclusion criteria; mortality occurred in 25.6%, and 54.9% underwent a neurosurgical procedure. All 3 scores were associated with mortality in univariate analyses. In multivariate modeling with age and the scores, the St. Louis score remained the strongest mortality predictor (adjusted OR 1.33, p = 0.013) and showed the highest discrimination (AUC 0.85) with a clinical threshold of 6.5. The SPIN score showed good discrimination (AUC 0.81) with a threshold of 31 and outperformed the Baylor score despite lacking imaging inputs; the Baylor score had lower overall discrimination. For neurosurgical intervention, only EVD placement showed significant univariate associations (St. Louis, SPIN, and age). In multivariate models, St. Louis and SPIN did not retain significance for EVD, but both demonstrated modest discrimination (SPIN AUC 0.671; St. Louis AUC 0.652) and high sensitivity/negative predictive value, supporting use as rule-out tools. No significant associations were observed for ICP monitor placement, craniotomy, or DHC. CONCLUSIONS: The authors' findings support a pragmatic, two-step workflow: use the SPIN scale at first contact, before neuroimaging, to inform triage, then apply the St. Louis scale after imaging to refine prognosis. Predefined cut points for mortality (SPIN score ≤ 31; St. Louis score ≥ 7) and EVD placement (SPIN score ≤ 41; St. Louis score ≥ 2) can standardize bedside decision-making. Their complementary nature suggests their use at different points of patient management to optimize their clinical utility.
Association between persisting peritumoral brain edema and seizures as well as worse functional outcome after meningioma surgery: a retrospective study of 218 patients.
Laajava J, Niemelä M, Korja M
J Neurosurg · 2026 Jun · PMID 42320065 · Publisher ↗
OBJECTIVE: Peritumoral brain edema (PTBE) of intracranial meningioma (IM) often persists after gross-total resection (GTR) and likely represents reactive gliosis. The authors investigated whether persisting PTBE (i.e., F...
OBJECTIVE: Peritumoral brain edema (PTBE) of intracranial meningioma (IM) often persists after gross-total resection (GTR) and likely represents reactive gliosis. The authors investigated whether persisting PTBE (i.e., FLAIR hyperintensity) is associated with postoperative seizures and functional outcomes, hypothesizing that it is associated with a higher likelihood of seizures and worse outcomes. METHODS: The authors retrospectively reviewed all patients (age ≥ 18 years) with IM who underwent GTR at their institution between 2000 and 2020. Included patients had a preoperative MRI study showing PTBE and at least a 2-year MRI follow-up. Univariable and multivariable analyses identified factors associating with seizures and functional outcome (Karnofsky Performance Status [KPS]). Postoperative electroencephalography (EEG), when available, was reviewed to locate epileptogenic foci. RESULTS: Among 218 adult IM patients with preoperative PTBE, preoperative seizures occurred in 94 (43.1%). Seizures persisted in 27 (28.7%) patients after surgery (mean time to first postoperative seizure 8.4 months). Of the 124 patients without preoperative seizures, 18 (14.5%) developed new-onset postoperative seizures (mean time to first seizure 7.6 months). Persisting PTBE volume in the highest tertile (median 12.8 cm3, range 6.7-54.0 cm3) was associated (p = 0.03, OR 4.7) with new-onset seizures in comparison with the lowest tertile (median 0.5 cm3, range 0.0-1.6 cm3). An increase in postoperative PTBE volume was also associated with new-onset seizures (p = 0.008, OR 6.7) and persisting seizures (p = 0.004, OR 4.4). Postoperative EEG was available for 23 patients, of whom 10 (43.5%) had an epileptogenic focus at the site of persisting PTBE. Larger persisting PTBE volumes were associated with worse postoperative KPS (p = 0.04, OR 1.03 per cm3 increase). CONCLUSIONS: Persisting PTBE is associated with worse functional outcome and with persisting and new-onset seizures. Based on EEG findings, persisting PTBE (i.e., gliosis) may be the epileptogenic focus in some patients. Future studies are needed to assess whether these gliotic sites could even be therapeutic targets for seizure control.
Letter to the Editor. A ligament-based perspective on medial cavernous sinus wall invasion.
Carpenter A, Nair P
J Neurosurg · 2026 Jun · PMID 42320064 · Publisher ↗
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Editorial. The timing dilemma in treating posthemorrhagic ventricular dilatation.
Bond KM, Salwi SR, Heuer GG
J Neurosurg Pediatr · 2026 Jun · PMID 42320060 · Publisher ↗
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Vagus nerve stimulation for refractory epilepsy: a 24-year single-center experience.
Khalid MU, Hussain N, Ward Mitchell R … +12 more , Ainger T, Clay JL, Youssefi J, Mathias S, Mahuwala Z, Haghighat Z, Khan GQ, Ebong IM, Kapoor S, Bensalem-Owen M, Pittman T, Mirza FA
J Neurosurg · 2026 Jun · PMID 42320059 · Publisher ↗
OBJECTIVE: Approved in 1997, vagus nerve stimulation (VNS) is now a mainstay treatment of refractory epilepsy. While the safety and efficacy of this treatment modality are well established, the authors investigated the p...
OBJECTIVE: Approved in 1997, vagus nerve stimulation (VNS) is now a mainstay treatment of refractory epilepsy. While the safety and efficacy of this treatment modality are well established, the authors investigated the patient- and disease-related factors that impact efficacy. METHODS: The authors conducted a retrospective analysis of 356 patients who underwent VNS therapy at their center from 2000 to 2023. Data collected included age at implantation, age of first seizure, seizure type and etiology, seizure frequency and number of antiseizure medications before and after VNS, presurgical workup, and second surgery after VNS implantation. Responders were classified as those with at least 50% improvement in seizure frequency. Primary outcome was ≥ 50% reduction in seizure frequency. RESULTS: Age at implantation and sex had no significant effect on seizure frequency. Patients with low seizure frequency had a significantly better response than patients with other seizure frequencies. Patients with a baseline seizure frequency of 1-2/year (OR -3.14, 95% CI -5.371 to -0.909) had significantly better outcomes than the other groups, and patients with baseline seizure frequency of 1-2/month also had a significant outcome (OR -1.803, 95% CI -2.875 to -0.730). The authors' study showed no significant difference in VNS outcomes based on known etiology and imaging findings. Patients with 1-2 seizures/year also had a significant decrease in antiseizure medication burden after surgery (p = 0.026). CONCLUSIONS: This study showed that patients with refractory epilepsy who experience low baseline seizure frequency (< 1-2/month and < 1-2/year) received the most benefit from VNS. All patients with refractory seizures should be considered for VNS therapy but should undergo careful case selection to manage expectations and maximize seizure outcomes and medication burden.
Impact of a standardized documentation template on hospital case mix index and reimbursement for patients with traumatic brain and spine injuries.
Sethuraman A, Mahajan A, Podugu P … +13 more , Sharpe M, Nickell C, Owen P, Eidnani V, Woolnough J, Jankowski J, Davis J, Reddy D, Bowles A, Belding J, Ben-Israel D, Ho V, Kelly ML
J Neurosurg · 2026 Jun · PMID 42320058 · Publisher ↗
OBJECTIVE: The case mix index (CMI) measures the complexity and severity of hospitalized patients and is used to determine hospital reimbursement rates. Better documentation is associated with higher complexity assigned...
OBJECTIVE: The case mix index (CMI) measures the complexity and severity of hospitalized patients and is used to determine hospital reimbursement rates. Better documentation is associated with higher complexity assigned to cases as measured by CMI but remains understudied in the trauma population. The authors hypothesized that standardized templates for neurotrauma history and physical (H&P) notes are associated with increased CMI and reimbursement. METHODS: A multidisciplinary team consisting of trauma program professionals, trauma data specialists, neurosurgeons, revenue integrity specialists, and financial analysts created traumatic brain injury (TBI) and traumatic spine injury (TSI) H&P templates targeting Medicare Severity Diagnosis Related Groups (MS-DRGs). All neurotrauma cases from 2015 to 2023 were extracted from the electronic medical records with their accompanying diagnosis-related group weights and divided into pretemplate (pre-T) and posttemplate (post-T) groups. The hospital CMI and reimbursement were calculated for the TBI group, the TSI group, and a control group of patients with nonbrain or spine trauma. Comparisons were made between the pre-T and post-T groups. RESULTS: The authors included 5884 neurotrauma patients. TBI and TSI patients were similar in age and sex across time periods. The Injury Severity Score was significantly higher in the post-T period (p < 0.001). CMI was significantly higher for TBI and TSI in the post-T period (2.99 vs 2.51 for TBI, p < 0.001; 4.03 vs 3.42 for TSI, p < 0.001). CMI showed no increase in the post-T period for the nonbrain or spine trauma group (2.41 vs 2.38, p = 0.57). The post-T period demonstrated a significant increase in hospital reimbursement per discharge with a 13% increase for TSI and a 22% increase for TBI. CONCLUSIONS: Implementation of a neurotrauma documentation template was associated with increases in hospital CMI and reimbursement for TBI and TSI patients. Further studies are needed to explore how trauma documentation in other subpopulations is associated with hospital CMI and reimbursement.
Clinical efficacy analysis of percutaneous balloon compression in patients with trigeminal neuralgia.
Du Y, Wang Y, Guo W … +3 more , Xi Z, Sun G, Qian T
J Neurosurg · 2026 Jun · PMID 42320057 · Publisher ↗
OBJECTIVE: This study aimed to assess the clinical effectiveness of percutaneous balloon compression (PBC) for trigeminal neuralgia (TN) and develop a predictive model for treatment outcomes. METHODS: A retrospective ana...
OBJECTIVE: This study aimed to assess the clinical effectiveness of percutaneous balloon compression (PBC) for trigeminal neuralgia (TN) and develop a predictive model for treatment outcomes. METHODS: A retrospective analysis was conducted of TN patients who underwent PBC between September 2020 and September 2023. Propensity score matching was used to match ineffective and effective cases at a 1:4 ratio. Perioperative data were analyzed using t-tests and chi-square tests. LASSO (least absolute shrinkage and selection operator) regression identified relevant predictors, which were then used to build a multivariate logistic regression model. RESULTS: Among 230 matched patients, PBC was ineffective in 46 and effective in 184. Perioperative parameters differed significantly between the groups, while demographics did not. Balloon volume, compression duration, balloon pressure, and shape were identified as predictors of treatment outcomes. The model achieved an area under the curve of 0.890, indicating strong discriminative ability. CONCLUSIONS: PBC showed significant efficacy in treating TN. Balloon volume, compression duration, pressure, and shape were independent predictors of treatment outcomes.
Incomplete tumor resection, central neuroradiological review, and second surgery in pediatric patients with intracranial ependymoma treated in the E-HIT2000 trial.
Krajewski KL, Kammler G, Obrecht-Sturm D … +15 more , Mynarek M, Gerber NU, Juhnke BO, Benesch M, Friedrich C, von Bueren AO, Kwiecien R, Thomale U, Kortmann RD, Krauss J, Pietsch T, Bison B, Warmuth-Metz M, von Hoff K, Rutkowski S
J Neurosurg Pediatr · 2026 Jun · PMID 42320055 · Publisher ↗
OBJECTIVE: The purpose of this study was to review the assessment of residual tumor, analyze surgical factors associated with incomplete resection, determine the risk of neurological sequelae for reoperation, and assess...
OBJECTIVE: The purpose of this study was to review the assessment of residual tumor, analyze surgical factors associated with incomplete resection, determine the risk of neurological sequelae for reoperation, and assess the impact of second surgeries on survival. METHODS: Patients 0-21 years old with nonmetastatic intracranial ependymoma treated within the prospective multicenter E-HIT2000 trial were included. Prospective central neuroradiological review of pre- and postoperative imaging was performed. RESULTS: The 291 patients included in the E-HIT2000 trial underwent surgery at 71 centers in Germany, Austria, and Switzerland. Timely central review of postoperative imaging of sufficient quality was performed in 206 patients, and extent of resection was classified as gross-total resection (GTR) in 137 (67%) patients and incomplete with residual disease (RD) in 69 (33%) patients. Surgeons erroneously reported GTR in 11/40 patients with RD and available surgical reports; adhesions in the rhomboid fossa and/or brainstem were the most common reasons for intentional RD. Twenty-three of the 69 patients with RD underwent a second surgery as part of their primary treatment, 11 before and 12 after the start of adjuvant therapy; in 11/23 patients, GTR was achieved after a maximum of 3 procedures. The frequency of postoperative neurological deficits in the patients with second surgery did not differ from that in patients with primary GTR. Ten-year overall survival with GTR was 69.8% ± 4.4% versus 51.2% ± 7.1% with RD (p = 0.002). A second surgery significantly improved progression-free survival (42.4% ± 11.5% vs 22.2% ± 6.5% without second surgery, p = 0.004). CONCLUSIONS: Second surgery was not associated with an increased frequency of neurological sequelae and conferred an advantage in survival overall. The authors strongly recommend early central neuroradiological review to evaluate postoperative residual tumor and discuss reoperation. Further studies are needed to outline a tailored risk assessment for each patient based on molecular and clinical aspects.
Late cerebrospinal fluid shunt infections: a Hydrocephalus Clinical Research Network study.
Hersh DS, Jensen H, Reeder RW … +27 more , Nunn N, Hankinson TC, Staulcup S, Hauptman JS, Isaacs AM, Jackson EM, White S, Kulkarni AV, Dinger TF, Pindrik JA, Pollack IF, Davis D, Becerra J, Ravindra VM, Riva-Cambrin J, Rashid R, Rocque BG, Hale AT, Simon TD, Strahle JM, Landwehr F, Tamber MS, Weir A, Wellons JC, Reisen B, Whitehead WE, Kestle JRW
J Neurosurg Pediatr · 2026 Jun · PMID 42320054 · Publisher ↗
OBJECTIVE: Infection is a significant complication of CSF shunt surgery, with most infections occurring early in the postoperative course. While standardized perioperative protocols have successfully reduced early infect...
OBJECTIVE: Infection is a significant complication of CSF shunt surgery, with most infections occurring early in the postoperative course. While standardized perioperative protocols have successfully reduced early infections, the epidemiology, risk factors, and clinical patterns of late shunt infections are poorly characterized. This study aimed to determine the incidence, risk factors, clinical features, and outcomes of late shunt infections in a large, multicenter pediatric cohort. METHODS: The Hydrocephalus Clinical Research Network (HCRN) Core Data Project was queried for all CSF shunt procedures performed between November 2016 and June 2023 in patients younger than 18 years. Each shunt surgery was treated as an index surgery, defined as the starting point for subsequent infection surveillance. Shunt surgeries were assigned to one of the following categories: no infection, early infection (≤ 6 months after the surgery), or late infection (> 6 months after the surgery). Demographic, operative, and clinical features of early versus late infections were compared, and Cox proportional hazards models were developed to assess shunt survival following early versus late infections. RESULTS: Of 6698 shunt procedures, 285 (4.3%) were followed by early infections and 58 (0.9%) by late infections. Late infections accounted for 16.9% of all shunt infections. Late infections were significantly more likely than early infections to be associated with abdominal pseudocysts (24.1% vs 3.5%, p < 0.001) and less likely to be diagnosed via CSF culture (53.4% vs 78.6%, p < 0.001). Clinical events that took place between the shunt surgery and the late infection included abdominal surgeries (21.4%), shunt taps (23.2%), bacteremia (9.1%), and nonoperative abdominal processes requiring hospitalization (19.6%). Vancomycin was administered less frequently in the late infection group (62.1% vs 85.3%, p < 0.001), and shunts were less likely to be initially treated with complete shunt removal (65.5% vs 88.4%, p < 0.001) and more likely to be initially managed with externalization of the distal catheter alone (34.5% vs 11.6%, p < 0.001). Shunt survival after infection did not differ significantly between early and late infections. CONCLUSIONS: Late CSF shunt infections are uncommon but clinically distinct from early infections and are often associated with heterogeneous secondary exposures not addressed by perioperative protocols. These findings highlight the need for long-term surveillance in patients with shunts, tailored diagnostic strategies, and expanded infection tracking efforts.
Surgical complications in early versus late intervention centers for progressive posthemorrhagic ventricular dilatation in preterm infants: a multicenter analysis.
Lai GY, van der Aa NE, Woerdeman PA … +12 more , Deliloglu B, Cizmeci MN, Wilson D, Kulkarni AV, Steggerda SJ, Koot RW, Lam S, Dizon MLV, Gupta N, Gano D, Limbrick DD, de Vries LS
J Neurosurg Pediatr · 2026 Jun · PMID 42320053 · Publisher ↗
OBJECTIVE: The aim of this study was to evaluate the clinical features and surgical complication rates of preterm infants with posthemorrhagic ventricular dilatation (PHVD) who underwent CSF diversion, comparing early in...
OBJECTIVE: The aim of this study was to evaluate the clinical features and surgical complication rates of preterm infants with posthemorrhagic ventricular dilatation (PHVD) who underwent CSF diversion, comparing early intervention (EI) and late intervention (LI). METHODS: This was a retrospective international multicenter study of infants born at ≤ 34 weeks' gestational age (GA) and treated between 2018 and 2022 for grade III or IV germinal matrix hemorrhage and intraventricular hemorrhage, who required intervention for PHVD. The primary outcome of interest was the rate of postoperative surgical complications. Secondary outcomes were rate of temporizing neurosurgical procedures (TNPs) after initial lumbar puncture (LP) if performed, rate of conversion from TNP to a ventriculoperitoneal shunt (VPS), and overall rate of VPS insertion. Summary statistics and univariable and multivariable logistic regression were performed to determine variables predictive of complications. RESULTS: One hundred seventy infants from 6 centers in the United States, Canada, and the Netherlands were included. Infants at LI centers were more premature (GA 26.7 ± 2.8 vs 29.3 ± 2.4 weeks, p < 0.001) with lower birth weights (BWs; 1004 ± 448 vs 1438 ± 462 g, p < 0.001) compared to those at EI centers. The first neurosurgical intervention occurred at a median day of life after birth (DOL) of 31.5 (IQR 24-45) days at LI centers versus 18 (IQR 13-21) days at EI centers (p < 0.001). Ventricular index (> 97th percentile) at the first neurosurgical intervention (TNP and/or VPS placement) was lower at EI centers (5.05 ± 2.32 vs 12.88 ± 5.70 mm, p < 0.001). Infant weight at the first neurosurgical intervention did not differ between site types (p = 0.466). EI centers had a larger proportion of patients who underwent LP (97% vs 58%, p < 0.001) and smaller proportion who required a VPS after TNP (42% vs 70%, p = 0.002). The overall VPS insertion rate was higher at LI centers (62% vs 30%, p < 0.001). There was no statistical difference in the complication rate between EI and LI centers (11% vs 24%, respectively, OR 0.42, 95% CI 0.12-1.24, p = 0.115). On univariable analysis, lower GA (p = 0.002), lower BW (p = 0.003), later DOL at first neurosurgical intervention (p = 0.035), diagnosis of meningitis before neurosurgical intervention (p = 0.047), and of necrotizing enterocolitis (p = 0.017) during the neonatal intensive care unit admission were predictive of complications. However, only lower GA (p = 0.029) and BW (p = 0.031) remained significant on multivariable analysis. CONCLUSIONS: The neurosurgical complication rate did not differ between EI and LI centers. On multivariable analysis, neurosurgical complications were associated with younger GA and lower BW but not with variables regarding the timing of intervention. These observations support cautious early CSF diversion in more preterm infants with lower BWs.
Editorial. Sooner rather than later? The subtle nature of late-presenting shunt infections.
Partington MD
J Neurosurg Pediatr · 2026 Jun · PMID 42320052 · Publisher ↗
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Angioarchitecture and classification of adult intracranial pial arteriovenous fistulas: a multicenter study.
Yamada H, Kaku Y, Mizutani K … +6 more , Hiramatsu M, Izumi T, Tanoue S, Kiyosue H, Akiyama T, JSNET Pial AVF Study Group Collaborators
J Neurosurg · 2026 Jun · PMID 42284618 · Publisher ↗
OBJECTIVE: Pial arteriovenous fistulas (AVFs) are rare cerebrovascular shunts characterized by direct connections between pial arteries and veins. Despite increasing recognition in adults, their anatomical features and c...
OBJECTIVE: Pial arteriovenous fistulas (AVFs) are rare cerebrovascular shunts characterized by direct connections between pial arteries and veins. Despite increasing recognition in adults, their anatomical features and clinical implications remain poorly understood. The authors aimed to characterize the clinical and radiological features of adult intracranial pial AVFs, propose an angioarchitectural classification, and assess treatment outcomes. METHODS: The authors conducted a nationwide, multicenter, retrospective cohort study of adult intracranial pial AVFs in Japan between 2013 and 2024. Imaging data were centrally reviewed to confirm diagnoses and classify lesions based on angioarchitecture. Lesions were defined as microfistulas when the diameter of the shunt feeder was < 2 mm and as macrofistulas when it was ≥ 2 mm. Clinical features, treatment strategies, and outcomes were compared descriptively between the groups. RESULTS: A total of 66 patients with 72 pial AVFs were analyzed. Compared with macrofistulas, microfistulas were more common (74.2%) and occurred more often in older patients (median age 66 vs 32 years, p < 0.001). Furthermore, dural AVFs (42.9% vs 5.9%, p = 0.006) and a history of cerebrovascular events (24.5% vs 0%, p = 0.027) were more frequently observed in microfistulas. Varix formation and multiple draining veins were commonly seen in macrofistulas (94.7% vs 7.5%, p < 0.001 and 21.1% vs 0%, p = 0.004, respectively). Among 72 lesions, 70.8% underwent intervention, with transarterial embolization being the most common modality (51.0%). Complete obliteration was achieved in 78.4% of treated cases. Each lesion was further subclassified into distinct subtypes based on angioarchitectural configuration. One macrofistula subtype (5.6%), characterized by multiple feeders connecting to different multiple draining veins, showed lower obliteration rates and higher complication rates in the few treated cases. CONCLUSIONS: Adult pial AVFs exhibit considerable angioarchitectural heterogeneity, which may relate to variations in clinical presentation and management. Our proposed classification scheme may provide a descriptive framework for characterizing these lesions, although further validation is needed.
Postconcussion physical activity frequency and plasma biomarker associations among adolescents.
Moseley RR, Wingerson MJ, Richardson KL … +6 more , Hurlburt KD, Warren K, Wilson JC, Meehan WP, Mannix R, Howell DR
J Neurosurg Pediatr · 2026 Jun · PMID 42284615 · Publisher ↗
OBJECTIVE: Existing studies have reported the utility of plasma biomarkers for concussion diagnosis and outcome prognostication. In parallel, physical activity (PA) after concussion is associated with better outcomes. Th...
OBJECTIVE: Existing studies have reported the utility of plasma biomarkers for concussion diagnosis and outcome prognostication. In parallel, physical activity (PA) after concussion is associated with better outcomes. Therefore, this study sought to investigate the association between PA frequency and plasma biomarker concentration levels following concussion. METHODS: The authors performed a cross-sectional analysis of adolescents diagnosed and evaluated within 21 days of a concussion. Participants self-reported engagement in PA as well as PA frequency since injury and underwent venipuncture. To account for variability in evaluation time, PA frequency was calculated as the percentage of days between concussion and initial evaluation in which PA was reported. Plasma analysis assays included glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), total tau, and neurofilament light chain (NF-L). RESULTS: A total of 57 adolescents participated, including 32 who reported participating in PA (mean age 15.9 [SD 1.7] years, 44% female, mean 13.0 [SD 3.8] days postinjury) and 25 who did not (mean age 15.5 [SD 1.4] years, 68% female, mean 10.6 [SD 3.6] days postinjury). Postconcussion PA frequency across the cohort was 29.3% (SD 23%, mean 3.6 [SD 3.0] days of PA since injury). A higher percentage of PA days postconcussion was associated with significantly lower levels of plasma GFAP (β = -0.52, 95% confidence interval [CI] -0.96 to -0.07; p = 0.02) and NF-L (β = -0.81, 95% CI -1.59 to -0.03; p = 0.04) after adjusting for age, sex, and symptom severity. Log-transformed coefficients indicated that for every 10% increase in the percentage of PA days since concussion, GFAP levels decreased by approximately 5.1% and NF-L levels decreased by approximately 7.9%. CONCLUSIONS: These results indicate that more frequent PA in the days after concussion was associated with decreased levels of two biomarkers, GFAP and NF-L. Given the relevance of plasma biomarkers as indicators of neurobiological cell damage and ongoing repair processes after concussion, these findings suggest that postconcussion PA is associated with improved biological as well as clinical recovery outcomes.
Letter to the Editor. Surgical skill is an expression of virtue.
Mok V, Graffeo CS
J Neurosurg · 2026 Jun · PMID 42284614 · Publisher ↗
Abstract loading — click title to view on PubMed.
Comparative sensitivity and specificity of change in third ventricular diameter or global ventricular change for detecting pediatric ventriculoperitoneal shunt malfunction: a 10-year retrospective cohort study.
Cho C, Coulthard LG, Harbison AM … +5 more , Ma N, Campbell RAJ, Jardim AJ, How E, Stuart MJ
J Neurosurg Pediatr · 2026 Jun · PMID 42284612 · Publisher ↗
OBJECTIVE: Clinical features of shunt malfunction are often nonspecific and neuroimaging is a well-established aid in diagnosis. In practice, qualitative assessment of overall ventricular change guides management; howeve...
OBJECTIVE: Clinical features of shunt malfunction are often nonspecific and neuroimaging is a well-established aid in diagnosis. In practice, qualitative assessment of overall ventricular change guides management; however, change in third ventricular diameter (TVD) alone has been proposed as a low-complexity quantitative index of overall ventricular change. This study aimed to evaluate the diagnostic utility of change in TVD compared with global assessment of ventricular caliber change by a neurosurgeon in detecting shunt malfunction. METHODS: A retrospective review of all pediatric ventricular shunt revisions performed at a single center (November 2014-September 2024) was conducted. TVDs were measured when the patient was last known well and on preoperative imaging. Quantitative change was compared to the overall impression of change in ventricular caliber by neurosurgeons for detecting shunt malfunction. Shunt malfunction was defined as the need to replace one or more shunt components at the time of surgery (diagnostic gold standard). Diagnostic performance was assessed using comparison of areas under the receiver operating characteristic (ROC) curve. RESULTS: A total of 422 shunt revisions were performed during the study period, of which 315 (75%) were found to have shunt malfunction. ROC analysis utilizing a cutoff of ≥ 2-mm TVD increase detected shunt malfunction with 63% sensitivity and 58% specificity (area under the curve [AUC] 0.62, 95% CI 0.55-0.69; p < 0.001). Pragmatic refinement by restricting the cohort to the subset of 136 patients known to have a change in ventricular caliber at the time of previous shunt failure and selecting a ≥ 1-mm cutoff increased the discriminative power of change in TVD to 92% sensitivity and 21% specificity. In this restricted cohort, the overall assessment of ventricular change by neurosurgeons yielded 81% sensitivity and 62% specificity (AUC 0.72, 95% CI 0.59-0.84) and the AUC difference between the two techniques was not statistically significant (AUC difference 0.08, 95% CI -0.03 to 0.20; p = 0.16). CONCLUSIONS: In a pragmatically selected cohort, an increase ≥ 1 mm from baseline TVD alone provides sensitivity comparable to that of overall assessment of ventricular change by a neurosurgeon identifying shunt malfunction in a cohort undergoing shunt revision. This simple linear measurement could be integrated as a screening test in clinical, imaging, and/or AI algorithms to facilitate rapid recognition of pediatric shunt failure.
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