2012 program book – st. louis, mo

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.

4

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

5

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)

6

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

7

8

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

9

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


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


2008 Ellen L. AirALongutudinalComparisonofPre-andPost-operativeDTIparametesinYoungHydrocephalicChildren

2009 Christopher JansonImmortalizationandFunctionalCharacterizationofRatArachnoidCells

2010 Ramin EskandariEffectsofEarlyAndLateReservoirTreatmentinExperimentalNeonatalHydrocephalus

2011 Ashley Grosvenor TianBilateralHighGradeIntraventricularHemorrhageisAssociatedWithMaleSex,YoungerGestationalAgeAndLowerBirthWeight,ButNotOtherPerinatalFactors

AWARD RECIPIENTSHYDROCEPHALUSASSOCIATIONAWARDRECIPIENTS

10

MEETING ROOM FLOOR PLAN

11

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.

12

13


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.

14


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


14

16

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)


6:45-7:45AM 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


6:45-7:45AM BreakfastSeminar:PrivatePracticevs.AcademicPediatricNeurosurgery



7:15AM-3:00PM ExhibitHallOpen&E-PosterViewing GrandBallroom

8:00AM-12:00PM Plenary&ScientificSessions RegencyBallroom


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



7:15-10:25AM ExhibitHallOpen&E-PosterViewing GrandBallroom

8:00-11:30AM Plenary&ScientificSessions RegencyBallroom


12:00-4:00PM PracticalClinic:NeuroendoscopyinthePediatricPatient PracticalAnatomy&SurgicalEducationLab(PASE)

TUES

DAY

Nov

embe

r27

W

EDN

ESD

AYN

ovem

ber2

8

THU

RSD

AYN

ovem

ber2

9

FRID

AYN

ovem

ber3

0

17

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


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


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


6:45–7:45AMBreakfast 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)

23

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)

24

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


6:45–7:45AMBreakfast Seminar: Private Practice vs. Academic Pediatric NeurosurgeryIllinois/NewYorkCentralRooms

Developingasuccessfulprivatepracticeinpediatricneurologicalsurgeryischallenging…butpossible.Buildingasuccessfulacademiccareerinpediatricneurologicalsurgeryrequiresdifferentstrategies.Comeandfindoutanswerstoyourquestions.

PanelistsCatherineAnneMazzola,MDNathanR.Selden,MD,PhD


7:00AM–4:00PMSpeaker Ready RoomTheDepot


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

25

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


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

26

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)

27

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

28

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


7:00–11:00AMSpeaker Ready RoomTheDepot


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

29

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


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.

30

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.

31

ORAL ABSTRACTS

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.

32

ORAL ABSTRACTS

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.

33

ORAL ABSTRACTS

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.

34

ORAL ABSTRACTS

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.

35

ORAL ABSTRACTS

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.

36

ORAL ABSTRACTS

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.

37

ORAL ABSTRACTS

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.

38

ORAL ABSTRACTS

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.

39

ORAL ABSTRACTS

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

40

ORAL ABSTRACTS

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.

41

ORAL ABSTRACTS

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.

42

ORAL ABSTRACTS

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.

43

ORAL ABSTRACTS

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.

44

ORAL ABSTRACTS

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.

45

ORAL ABSTRACTS

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.

46

ORAL ABSTRACTS

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.

47

ORAL ABSTRACTS

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.

48

ORAL ABSTRACTS

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.

49

ORAL ABSTRACTS

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.

50

ORAL ABSTRACTS

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.

51

ORAL ABSTRACTS

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.

52

E - POSTER ABSTRACTS

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.

53


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.

54


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.

55


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.

56


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.

57


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.

58


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.

59


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.

60


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

137. WITHDRAWN

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.

61


139. WITHDRAWN

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.

62


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.

63


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.

64


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.

65


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.

66


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).

67


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.

68


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.

69


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.

70


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.

71


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.

72


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.

73


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.

74


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.

75

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/[email protected],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

76

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

77


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

78


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


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


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


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


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


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


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


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


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

2012 program book – st. louis, mo

Documents