Sektionstage Herbst 2023 der Deutschen Gesellschaft für Neurochirurgie

Prof. Dr. med.

Univ.-Prof. Dr. med.

PD Dr. med.

Current status of the ESPN pediatric craniectomy and cranioplasty registry (PedCCR)

Abstract-Text Introduction In the pediatric age group the evidence regarding decompressive craniectomy (DC) is weak. Literature on pediatric cranioplasty is even more limited. Concerns are resorption of autologous bone flaps, skin breakdown and growth-related problems associated with synthetic implants. The relevance of DC and subsequent cranioplasty and the need for accurate and systematic data have led to the creation of the Pediatric Craniectomy &amp; Cranioplasty Registry (PedCCR) under the auspices of ESPN. Methods After thorough literature review, gaps in knowledge and evidence were identified and the following aims for PedCCR were defined: 1) Compare surgical practices regarding indication, timing and operative technique in a large multicenter cohort. 2) Provide outcome data in a large multicenter cohort. 3) Establish risk factors for complications and cranioplasty failure based on systematic data reaching back as far as the initial injury. Results The PedCCR is a prospective, multicenter, open registry enrolling children (≤16 years) undergoing DC and/or cranioplasty for any pathology. A steering committee will assure good scientific practice. Standardized questionnaires were designed and data will be collected online in an electronic joint database, which is currently in the testing phase. The core set of data comprises case report forms for DC, cranioplasty and follow-up visits for at least 24 months, with follow-up forms being recommended until adulthood. Incident reporting forms can be submitted for any incident or unscheduled operation. All forms allow reporting of basic data even in the absence of the patient, i.e. by telephone interview or written contact to parents/carers/treating physicians/rehabilitation clinic. Conclusions The PedCCR sets out to answer highly relevant open questions regarding pediatric DC and cranioplasty by using a high-quality prospective approach. The registry proposal was designed to maximize scientific yield at reasonable effort for participating centers. Collaboration is highly appreciated to advance this project together, as the registry is now recruiting.

Kraniektomie + Kranioplastie

Multizentrische Studien & Projekte

Abstractvortrag

Prof. Dr.

Ultraschnelle MRT-Sequenzen in der Kinderneurochirurgie – Eine bundesweite Expert:innen-Umfrage

Abstract-Text Hintergrund Ultraschnelle MRT-Sequenzen ermöglichen eine rasche Untersuchung des Neurocraniums bei Kindern ohne Notwendigkeit einer Anästhesiebegleitung sowie ohne Strahlenbelastung. Traditionell werden mit dieser Technik vor allem Kinder mit Hydrozephalus untersucht, wobei sich der Umfang der Indikationen stetig erweitert (Schädel-Hirn-Trauma, intrakranielle Zysten, Subduralhämatome/Hygrome usw.). Wir veranlassten eine bundesweite Umfrage über die Anwendung der ultraschnellen MRT-Sequenzen sowie über das Verbesserungspotential der zerebralen Diagnostik beim kinderneurochirurgischen Patientenkollektiv. Methoden Eine Umfrage mit 18 Fragen wurde auf dem Internetportal umfrageonline.com erstellt. Der Umfragelink wurde über den E-Mail-Verteiler der Sektion Pädiatrische Neurochirurgie verschickt, zudem wurden alle neurochirurgische Uniklinika angeschrieben sowie weitere neurochirurgische Kliniken, die mutmaßlich pädiatrische Patient:innen behandeln. Ergebnisse Vertreter:innen von 29 Kliniken nahmen an der Umfrage teil, davon wurden 25 Formulare weitestgehend ausgefüllt und 20 Formulare komplett abgeschlossen. Die meisten Respondent:innen arbeiten in NRW (11/25) sowie in einer Uniklinik (18/25). In 88% der teilnehmenden Kliniken werden oft Liquorshunt-OPs bei Kindern durchgeführt. Die Ventrikelweite bei shuntversorgten Kindern wird am häufigsten mit Ultraschall und konventioneller MRT (jeweils 19/26 Kliniken) eruiert, wobei Kinder mit einem leichten Schädel-Hirn-Trauma (SHT) am häufigsten mit konventioneller MRT (72%) gefolgt vom Ultraschall evaluiert werden. 56% (14/25) der Kliniken verfügen über die Möglichkeit, ultraschnelle MRT durchzuführen, wobei in den meisten Kliniken (7/13) die Technik 1-5 Jahre etabliert ist und oft bis sehr oft angewendet wird. Am häufigsten werden ultraschnelle Sequenzen bei Hydrozephalus durchgeführt (12/13), gefolgt von SHT (8/13), Subduralhämatomen und Zysten (jeweils 7/13). In 8/13 Kliniken werden die Kinder nie oder selten sediert. Die am häufigsten angewendete Sequenz ist T2-HASTE. Zu den wichtigsten Vorteilen der ultraschnellen MRT wurden die nicht notwendige Sedierung, kurze Akquisitionszeit, fehlende Strahlenbelastung und schnellere Verfügbarkeit genannt. Acht von neun Teilnehmer:innen, denen aktuell keine ultraschnellen Sequenzen zur Verfügung stehen, hätten Interese an der Implementierung. 4/12 Respondent:innen gaben an, dass Schwierigkeiten in der Absprache zwischen Neurochirurgie und (Neuro-)Radiologie die Etablierung der ultraschnellen Sequenzen verhindert haben. Kindergerechte Umgebung, Musik/Video im MRT-Gerät und Erklärfilme gehören zu weiteren erwünschten Maßnahmen zur Optimierung der MRT-Untersuchung. Schlussfolgerung Ultraschnelle MRT-Sequenzen finden langsam Einzug in die kinderneurochirurgische Routine an deutschen Kliniken. Kliniken, die die Technik noch nicht benutzen, haben Interesse an deren Implementierung. Zudem wären weitere Maßnahmen zur Optimierung der MRT-Untersuchung erwünscht.

Freie Themen

Dr. med.

Real-life impact of randomized controlled trials in pediatric neurosurgery: BASICS trial

Abstract-Text Background While randomized controlled trials (RCT) provide high internal validity, the generalizability of study results to typical patient populations in the real world setting can be limited. The BASICS trial was a multicenter single-blinded RCT comparing standard shunts versus antibiotic-impregnated shunts (AIS) versus silver-coated shunts with regard to shunt infection in patients who receive their first shunt. The RCT revealed a significant reduction of shunt infection with AIS, with a cause-specific hazard ratio of 0.38. Here we present our analysis of the impact of implementing these RCT findings into routine clinical practice. Methods Based on ICD- and OPS-coding, we retrospectively indentified patients who received shunts insertions between 2012 and 2023. Years prior to implementation of AIS in late 2019 were compared to the following years. The 30 day shunt infection rate was analyzed as the outcome parameter. Results The overall number of shunt insertions was N = 1,921. The overall 30 day shunt infection rate before 2020 was 2.8%. After implementation of AIS the rate was 0.8%. In the pediatric subgroup the rates were 3.1% and 1.2%, respectively. Discussion After publication of the BASICS trial results in late 2019 we quickly implemented AIS into routine clinical care at our institution, and subsequently the 30 day shunt infection rate could be reduced to 0.8% in the overall cohort and 1.2% in the pediatric cohort. Thus the positive results from the RCT could be successfully reproduced in a real-life setting, with a 30-40% reduction in shunt infections.

Prof.

Alterations of neurosurgical resection patterns for pediatric low-grade glioma during the German LGG-studies 1996-2018

Abstract-Text Neurosurgery remains the mainstay of treatment for pediatric low-grade glioma (LGG). Previous reports emphasized that extent of resection determines subsequent treatment stratification, but needs to be balanced against the risks of neurological morbidity. We investigated surgical resection patterns over 20 years within the German HIT-LGG studies. A total of 4270 pediatric LGG patients from three successive LGG studies (median age at diagnosis: 7.6 years, NF1 14.7%) were grouped into 5 subsequent time intervals (TI1-5) for date of diagnosis and analyzed for timing and extent of 1st surgery with respect to tumor location, histology, NF1 status, and age. Out of the entire cohort, 3440 patient received at least one surgical intervention. During the observation period, the fraction of non-operated LGG (radiological diagnosis) increased over time (TI1 12.6%; TI5 21.7%). In surgically treated patient"s the extent of first neurosurgical intervention showed a reduced complete/subtotal resection rate from TI1 to TI5, predominantly observed in the supratentorial midline tumor location, while partial resection rates increased and biopsy rate remained rather stable. The alterations in extent of surgical resections did not relate to changes in patients characteristics or anatomical conditions, but reflected adaptations to recommendations and comprehensive treatment algorithms of pediatric LGG patients. Further investigations are necessary to elucidate how planning and performance of surgery or tumor characteristics impact upon long term quality of life.

Pädiatrische Tumoren

Prof. Dr. med

Preoperative language mapping in children – A systematic review

Abstract-Text Objective In pediatric brain tumor / epilepsy surgery, preserving eloquent areas is essential beside sufficient resection margins. Electrical stimulation mapping (ESM) and the Wada-procedure are accepted as gold standards for the assessment of language function. However, both methods are invasive with varying degrees of feasibility. The aim of this review was to summarize preoperative language mapping data in children either for identification of hemispheric language dominance or localization of language-eloquent regions, highlighting the feasibility, strengths and limitations of the aforementioned methods and noninvasive alternatives. Methods A systematic review was conducted using the database PubMed and was registered before in the PROSPERO register. The following keywords were employed to identify articles eligible for review: [language, brain mapping, children]. Results Thirty-eight articles examining invasive (ESM, Wada-testing, electrocorticography (ECOG)) and noninvasive methods (task based- and resting-state fMRI, repetitive navigated TMS (rnTMS), magnetoencephalography and tractography) were included. Most studies (n=23) were feasibility analyses of the respective methods, whereas 16 validation studies were identified (11 with ESM and 5 with Wada-testing). Mapping paradigms differed significantly between study centers. Invasive methods require extensive compliance resulting in success rates of 19% (3/19) for children below 10 years, and seizures in up to 35% (43/122) of patients undergoing ESM. Non-invasive alternatives proved to be safe and could be integrated into clinical routine, with MEG and tb-fMRI mostly utilized for determination of hemispheric dominance and rnTMS and tractography analyzed for identification of eloquent areas. For determination of hemispheric dominance, tb-fMRI and MEG displayed concordance rates with invasive mapping ranging from 0.29-0.89. rnTMS and tractography identified eloquent areas with sensitivities between 0.20-0.97. Postoperative outcomes were reported in 13 studies (available for 174/1075 patients) whereby language outcome prediction was aimed only in two cohorts (ECOG and tractography). Resection of ECOG hotspots was not associated with (worse) postoperative language outcome. In contrast, injury of subcortical language network significantly correlated with postoperative language impairment (R=0.7, p&lt;0.001). Conclusion The challenges in pediatric neurosurgery are mirrored in the limited number of published studies in which postoperative outcomes are rarely reported. However, there are suitable alternatives to invasive mapping methods, each with individual advantages and disadvantages for determining the language-dominant hemisphere or for spatial location analysis of language-eloquent areas. Prospective, multicenter studies should be initiated to further improve/validate these methods.

Seminarraum 3

Pädiatrische Neurochirurgie

Multizentrische Studien & Projekte


Sektion Pädiatrische Neurochirurgie 

Pädiatrische Neurochirurgie
Multizentrische Studien & Projekte

Termin

Vorsitzende

Programm

Pädiatrische NeurochirurgieMultizentrische Studien & Projekte

Termin

Vorsitzende

Programm

Pädiatrische Neurochirurgie
Multizentrische Studien & Projekte