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Pediatric Vascular Neurosurgery: Principles And...

Pediatric Vascular Neurosurgery: Principles And... -

Residents learn to evaluate and manage children of all age ranges that require all types of procedures in pediatric neurosurgery. They are exposed to the full spectrum of neurosurgical conditions that affect children. The depth of this clinical exposure is distinctive. It includes the surgical management of intracranial congenital disorders, hydrocephalus, brain and spinal cord tumors, epilepsy, craniosynostosis and complex craniofacial conditions, spinal dysraphism, vascular disorders (both endo- and open), cranio-cervical and traumatic spinal deformities, spasticity and movement disorders, and trauma. Trainees develop operative skills in microsurgery, endoscopy, radiosurgery, and endovascular therapies during their time on the pediatric service. Junior and mid-level residents work directly with the pediatric neurosurgery faculty and fellows without intermediary senior or chief residents. They gain more opportunities for increased responsibility. Our residents have described this rotation as a time when both their clinical decision-making, operative skills, and critical thinking have matured. Residents operate almost daily, and have frequent opportunities to work on their microsurgical skills.

The pediatric service also educates residents in the value of teamwork, cooperation, and compassionate care through its partnerships in several multidisciplinary programs. Residents actively participate in conferences and clinics. We are part of comprehensive programs in spina bifida, neuro-oncology, craniofacial disorders, surgical epilepsy, spasticity, cerebrovascular disorders of childhood, trauma, fetal care, and neonatal injury.

We offer a robust didactic curriculum to support the educational experience. Knowledge in the evaluation and operative management of patients is supplemented through a daily afternoon conference to review elective cases for the upcoming day. A weekly educational conference is conducted each Thursday at noon. The schedule has been developed to enhance the understanding of basic pediatric neurosurgical principles and conditions. It includes a quality improvement (morbidity and mortality) conference, faculty lecture conference, journal club, and house officer presentation conference each month. In addition, faculty offer and provide exposure to a myriad of clinical research opportunities to those who seek such.

UT Southwestern Medical Center has three Neurocritical Care Units: a 24-bed unit at the Clements University Hospital, a 12-bed unit at Parkland Hospital and a 12-bed unit at Texas Health Presbyterian Hospital. Neurosurgery residents usually spend two 3-month blocks at the Clements University Hospital Neurocritical Care Unit. Residents are exposed to a variety of neurological and neurosurgical conditions including hemorrhagic and large ischemic strokes, status epilepticus, traumatic brain injury, etc. This rotation gives them the opportunity to learn and implement the principles of cerebrovascular pathophysiology and autoregulation, management of raised intracranial pressure, treatment of cerebral vasospasm, determination of brain death and management of intractable seizures. In addition, the residents also learn the principles of general critical care including mechanical ventilation, hemodynamic management and management of infections. Procedural skills such as placement of arterial and central venous catheters and point-of-care ultrasound are taught. Bedside teaching is supplemented with didactic lectures, journal clubs, debates, quizzes and sessions in our simulation center.

Navarro R, Chao K, Gooderham PA, Bruzoni M, Dutta S, Steinberg GK. Less invasive pedicled omental-cranial transposition in pediatric patients with moyamoya disease and failed prior revascularization. Neurosurgery. 2014;10 Suppl 1:1-14.

Teo MK, Johnson J, Steinberg GK: Pediatric moyamoya disease: Indirect revascularization. In: Britz (ed), A comprehensive guide to pediatric neurosurgical disorders and its management. Springer-Verlag, 2016 (in press)

Under the tutelage of Dr. R. Michael Scott, we have continued to refine a novel, cutting-edge surgery for children with moyamoya based on the procedure of pial synangiosis, pioneered by Dr. Scott here at Boston Children's. Surgery has proven to be the only effective long-term treatment for this disease and we are a global leader in treating children with this disorder. Our department heads one of the world's largest pediatric moyamoya programs, with 40 to 50 operations annually and more than 1,000 revascularization procedures performed overall. This high-volume international practice is mirrored throughout our department, particularly in regard to cerebrovascular malformations and brain tumors. This has enabled me and my colleagues to develop a number of important innovations, including advances in minimally invasive skull base endoscopic techniques in young children and new perioperative and surgical approaches for moyamoya and arteriovenous malformation patients.

At Vanderbilt the fellow will manage the entire Vanderbilt Pediatric Neurosurgery Service with oversight by the pediatric neurosurgical attending surgeons. This includes inpatient, operative, outpatient, clinic, educational, and research responsibilities. The fellow will have the opportunity to master the fundamentals of pediatric neurosurgery including management of brain tumors, vascular malformation, trauma, hydrocephalus, epilepsy, craniofacial, spasticity, spine disorders, congenital malformations, and peripheral nerve disorders. Unique to Vanderbilt, the fellow will have the opportunity to learn fetal myelomeningocele closure, as well as specialized endoscopic treatments of infant hydrocephalus, minimally invasive treatments using laser interstitial thermal therapy, stereo EEG, pediatric scoliosis treatment, brachial plexus surgery, and pediatric endonasal surgery. Training will not be limited to medical knowledge and operative technique; there will be an emphasis on professionalism, practice-based learning, communication skills, and systems based practice. Additionally, the fellow will be engaged with the Surgical Outcomes for Kids (SOCKs) research team to investigate important pediatric neurosurgical research questions.

Objective: To report our experience using Onyx in pediatric patients for a variety of cranial and spinal vascular lesions and tumors to determine its procedural complication rates, types, and clinical consequences and to highlight the indications for and principles of Onyx embolization in pediatric patients.

Methods: All pediatric Onyx embolization cases performed consecutively by the neuroendovascular services at our 2 institutions over a 5-year period were collected retrospectively and analyzed.

Results: Over the study period, 105 Onyx embolization procedures were performed in 69 pediatric patients with a mean follow-up of 112 days. Fifty-two patients harbored "primary" vascular lesions (malformations, fistulas, etc), whereas 17 patients had tumors. Complications occurred in 25 of 105 procedures (23.8%) and included ischemic infarct (7), asymptomatic nontarget embolization (4), intracerebral hemorrhage (3), microcatheter-related vessel perforation (3), retained microcatheter (2), cerebral edema (2), dimethyl sulfoxide-induced pulmonary edema (2), facial ischemia (1), and contrast-induced bronchospasm (1). Neurological morbidity occurred transiently after 10 procedures (9.5%) and permanently after 2 procedures (1.9%). There were no procedure-related deaths. Statistical analysis revealed no predictors of complications among the multiple potential risk factors evaluated.

Conclusion: Our experience suggests that Onyx can be used effectively for embolization of pediatric cranial and spinal vascular lesions and tumors with low permanent morbidity; however, attention must be paid to the technical nuances of and indications for its use to avoid potential complications.

Dr. Adelson is a renowned expert in pediatric neurosurgery with extensive experience in epilepsy surgery, CNS tumors and vascular malformations, and management of brain, spinal cord, and brachial plexus/peripheral nerve injuries.

Dr. Adelson is a renowned expert in pediatric and adult neurosurgery with extensive experience in epilepsy surgery, CNS tumors and vascular malformations, and management of brain, spinal cord, and brachial plexus/peripheral nerve injuries.

Dr. Adib A. Abla is a vascular and endovascular neurosurgeon who specializes in treating conditions involving blood vessels in the brain. These include brain aneurysms, arteriovenous malformations, cavernous malformations, arteriovenous fistulas, stroke and carotid artery disease. He performs both traditional open surgery and minimally invasive endovascular procedures, offering patients a comprehensive set of treatment options. He cares for both adult and pediatric patients.

Pial synangiosis is a method of indirect surgical revascularization developed at our institution for the treatment of moyamoya disease in pediatric patients. Similar surgical principles are employed in adult cases, often performed because of lack of an adequate donor vessel. Standardized protocols, including preadmission for preoperative intravenous hydration and aspirin administration, as well as intraoperative electroencephalography, are routinely employed to minimize operative risk. Perioperative heparinization is not required. The patient is positioned supine, without skull fixation, and the parietal branch of the superficial temporal artery is mapped with Doppler ultrasonography. The artery is microscopically dissected from distal to proximal, leaving a cuff of tissue around the vessel and elevated from the temporalis. The microscope is then removed, the temporalis is opened in a cruciate fashion, and a generous craniotomy is performed, with care to drill away from the exposed artery. The dura is then opened widely (preserving dural collateral vessels), followed by microscopic opening of the arachnoid in as many areas as possible. The donor vessel is then sutured to the pia with 10-0 nylons. The dural leaflets are laid on the brain (without suturing). Closure is completed with saline-soaked gelfoam, with fixation of the bone flap, and muscle reapproximation in the horizontal plane. The galea is closed, followed by the use of resorbable skin suture in pediatric patients. If indicated, the second hemisphere may be performed under the same anesthetic, reducing anesthetic risks and avoiding delayed revascularization. Postoperatively, the patient is awakened and transferred to the intensive care unit. 59ce067264

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