Case Studies - Pedi Neurosurgery

MassGeneral Hospital for Children’s Pediatric Neurosurgery Program is working to advance surgical treatment options and overall care of children with nervous system problems at all levels of severity.

Case Studies - Key Points
  • MassGeneral Hospital for Children (MGHfC) researchers are studying how the pediatric brain repairs itself and recovers function following trauma, including surgical trauma
  • Researchers have discovered that many pediatric neurology patients suffer undetectable seizures, which may affect outcomes
  • Using continuous EEG monitoring, MGHfC researchers are currently studying the frequency of seizures among pediatric intensive care patients and will examine the benefits of seizure intervention
  • Neurosurgeons at MGHfC perform many rare and complex surgical interventions for epilepsy, such as hemispheric disconnection and other functional procedures
Duhaime AC, Beckwith JG, Maerlender AC, McAllister TW, Crisco JJ, Duma SM, Brolinson PG, Rowson S, Flashman LA, Chu JJ, Greenwald RM.
Department of Neurosurgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts 02114, USA.
Abstract
OBJECT: Concussive head injuries have received much attention in the medical and public arenas, as concerns have been raised about the potential short- and long-term consequences of injuries sustained in sports and other activities. While many student athletes have required evaluation after concussion, the exact definition of concussion has varied among disciplines and over time. The authors used data gathered as part of a multiinstitutional longitudinal study of the biomechanics of head impacts in helmeted collegiate athletes to characterize what signs, symptoms, and clinical histories were used to designate players as having sustained concussions.
METHODS: Players on 3 college football teams and 4 ice hockey teams (male and female) wore helmets instrumented with Head Impact Telemetry (HIT) technology during practices and games over 2-4 seasons of play. Preseason clinical screening batteries assessed baseline cognition and reported symptoms. If a concussion was diagnosed by the team medical staff, basic descriptive information was collected at presentation, and concussed players were reevaluated serially. The specific symptoms or findings associated with the diagnosis of acute concussion, relation to specific impact events, timing of symptom onset and diagnosis, and recorded biomechanical parameters were analyzed.
RESULTS: Data were collected from 450 athletes with 486,594 recorded head impacts. Forty-eight separate concussions were diagnosed in 44 individual players. Mental clouding, headache, and dizziness were the most common presenting symptoms. Thirty-one diagnosed cases were associated with an identified impact event; in 17 cases no specific impact event was identified. Onset of symptoms was immediate in 24 players, delayed in 11, and unspecified in 13. In 8 cases the diagnosis was made immediately after a head impact, but in most cases the diagnosis was delayed (median 17 hours). One diagnosed concussion involved a 30-second loss of consciousness; all other players retained alertness. Most diagnoses were based on self-reported symptoms. The mean peak angular and rotational acceleration values for those cases associated with a specific identified impact were 86.1 ± 42.6g (range 16.5-177.9 g) and 3620 ± 2166 rad/sec( 2 ) (range 183-7589 rad/sec( 2 )), respectively.
CONCLUSIONS: Approximately two-thirds of diagnosed concussions were associated with a specific contact event. Half of all players diagnosed with concussions had delayed or unclear timing of onset of symptoms. Most had no externally observed findings. Diagnosis was usually based on a range of self-reported symptoms after a variable delay. Accelerations clustered in the higher percentiles for all impact events, but encompassed a wide range. These data highlight the heterogeneity of criteria for concussion diagnosis, and in this sports context, its heavy reliance on self-reported symptoms. More specific and standardized definitions of clinical and objective correlates of a "concussion spectrum" may be needed in future research efforts, as well as in the clinical diagnostic arena.
Comment in: Sports and concussion. [J Neurosurg. 2012] PMID: 23030057 [PubMed - indexed for MEDLINE]
J Neurosurg. 2012 Dec;117(6):1092-9. doi: 10.3171/2012.8.JNS112298. Epub 2012 Oct 2. PMID: 23030057 [PubMed - indexed for MEDLINE]

Walcott BP, Nahed BV, Kahle KT, Duhaime AC, Sharma N, Eskandar EN
Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA.
Abstract
Generalized dystonic syndromes may escalate into persistent episodes of generalized dystonia known as status dystonicus that can be life-threatening due to dystonia-induced rhabdomyolysis and/or respiratory compromise. Treatment of these conditions usually entails parenteral infusion of antispasmodic agents and sedatives and occasionally necessitates a medically induced coma for symptom control. The authors report a series of 3 children who presented with medically intractable, life-threatening status dystonicus and were successfully treated with bilateral pallidal deep brain stimulation. Bilateral globus pallidus internus stimulation appears to be effective in the urgent treatment of medically refractory and life-threatening movement disorders.
J Neurosurg Pediatr. 2012 Jan;9(1):99-102. doi: 10.3171/2011.10.PEDS11360. PMID: 22208329 [PubMed - indexed for MEDLINE]

McAllister TW, Flashman LA, Maerlender A, Greenwald RM, Beckwith JG, Tosteson TD, Crisco JJ, Brolinson PG, Duma SM, Duhaime AC, Grove MR, Turco JH.
Bioengineering Laboratory, Department of Orthopaedics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island 02903, USA.
Abstract
OBJECTIVE: To determine whether exposure to repetitive head impacts over a single season negatively affects cognitive performance in collegiate contact sport athletes
METHODS: This is a prospective cohort study at 3 Division I National Collegiate Athletic Association athletic programs. Participants were 214 Division I college varsity football and ice hockey players who wore instrumented helmets that recorded the acceleration-time history of the head following impact, and 45 noncontact sport athletes. All athletes were assessed prior to and shortly after the season with a cognitive screening battery (ImPACT) and a subgroup of athletes also were assessed with 7 measures from a neuropsychological test battery.
RESULTS: Few cognitive differences were found between the athlete groups at the preseason or postseason assessments. However, a higher percentage of the contact sport athletes performed more poorly than predicted postseason on a measure of new learning (California Verbal Learning Test) compared to the noncontact athletes (24% vs 3.6%; p < 0.006). On 2 postseason cognitive measures (ImPACT Reaction Time and Trails 4/B), poorer performance was significantly associated with higher scores on several head impact exposure metrics.
CONCLUSIONS: Repetitive head impacts over the course of a single season may negatively impact learning in some collegiate athletes. Further work is needed to assess whether such effects are short term or persistent.
Comments In: How many HITS are too many?: The use of accelerometers to study sports-related concussion. [Neurology. 2012]
Neurology. 2012 May 29;78(22):1777-84. doi: 10.1212/WNL.0b013e3182582fe7. Epub 2012 May 16. PMID: 22592370 [PubMed - indexed for MEDLINE]

Crisco JJ, Wilcox BJ, Beckwith JG, Chu JJ, Duhaime AC, Rowson S, Duma SM, Maerlender AC, McAllister TW, Greenwald RM.
Bioengineering Laboratory, Department of Orthopaedics, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island 02903, USA.
Abstract
In American football, impacts to the helmet and the resulting head accelerations are the primary cause of concussion injury and potentially chronic brain injury. The purpose of this study was to quantify exposures to impacts to the head (frequency, location and magnitude) for individual collegiate football players and to investigate differences in head impact exposure by player position. A total of 314 players were enrolled at three institutions and 286,636 head impacts were recorded over three seasons. The 95th percentile peak linear and rotational acceleration and HITsp (a composite severity measure) were 62.7g, 4378rad/s(2) and 32.6, respectively. These exposure measures as well as the frequency of impacts varied significantly by player position and by helmet impact location. Running backs (RB) and quarter backs (QB) received the greatest magnitude head impacts, while defensive line (DL), offensive line (OL) and line backers (LB) received the most frequent head impacts (more than twice as many than any other position). Impacts to the top of the helmet had the lowest peak rotational acceleration (2387rad/s(2)), but the greatest peak linear acceleration (72.4g), and were the least frequent of all locations (13.7%) among all positions. OL and QB had the highest (49.2%) and the lowest (23.7%) frequency, respectively, of front impacts. QB received the greatest magnitude (70.8g and 5428rad/s(2)) and the most frequent (44% and 38.9%) impacts to the back of the helmet. This study quantified head impact exposure in collegiate football, providing data that is critical to advancing the understanding of the biomechanics of concussive injuries and sub-concussive head impacts.
J Biomech. 2011 Oct 13;44(15):2673-8. doi: 10.1016/j.jbiomech.2011.08.003. Epub 2011 Aug 27. PMID: 21872862 [PubMed - indexed for MEDLINE]

Neurosurgical Teams Advance Preservation, Improvement of Pediatric Brain Function
Pediatric neurosurgery focuses on the surgical treatment of a wide range of brain and spine disorders, many of which remain incompletely understood. The pathophysiology of these disorders is especially complex among pediatric patients because factors such as the location of an injury or abnormality occurring in the brain during a particular stage of the child’s development can greatly influence outcomes. Advances in basic science research on the developing brain, along with technologic advances in surgical and imaging techniques, have opened new opportunities for the treatment of pediatric neurosurgical disorders. Because some of the most promising technologic advances have arisen from disorders commonly encountered in the adult population, an environment in which aspects of collaborative research and clinical care coexist across the age spectrum provides fertile ground for the application of new techniques to the care of children.
MassGeneral Hospital for Children (MGHfC) is a leader in the evaluation and surgical treatment of children with pediatric nervous system disorders, including epilepsy, brain tumors, traumatic brain injuries, spasticity, severe movement disorders, hydrocephalus, and congenital anomalies of the spine and brain. The overall goal of MGHfC’s Pediatric Neurosurgery Program is to first preserve and then improve brain function.
Pediatric neurosurgeons and their colleagues in many specialties at MGHfC care for some of the most severely ill and injured brain and spinal cord patients in the United States and from around the world. Through this unique expertise, they are working to advance surgical treatment options and overall care of children with nervous system problems at all levels of severity.

Brain Injury Research Leads to Better Surgical Planning
Ann-Christine Duhaime, MD, director of pediatric neurosurgery at MGHfC, leads a research team to study certain aspects of brain function and injury in children. This research is focused on learning how the pediatric brain responds to trauma, including the brain’s ability to repair itself and recover function, at different stages of development from infancy through adolescence. Although the team is examining brain function following mechanical trauma, the findings can be translated to trauma of any kind, including that induced by surgical interventions.
Dr. Duhaime’s research has led to a greater understanding of the pediatric brain response to certain types of injury and of the circumstances that optimize recovery. Based on this research, MGHfC’s Pediatric Neurosurgical Program, in conjunction with other specialists, including those in critical care, neurology, radiology, and trauma, is continuously adapting and improving clinical practices. For example, new radiology protocols detect problems early in a patient’s course that can direct interventions, including surgical treatments, to limit brain swelling and compression of vital structures, thus reducing the chance of additional injury.

Subclinical Seizures in Pediatric Patients

Seizures are especially dangerous to young children with neurological problems because continuous or frequent seizures may be particularly toxic to the developing brain. Understanding the prevalence of otherwise undetectable seizure activity may change treatment options for many young patients.

While continuous EEG monitoring is used in many pediatric centers to assess children with known epilepsy, MGHfC is among only a few centers in the country to offer this type of continuous EEG monitoring in the PICU setting for a wide variety of acute illnesses. The PICU is currently developing guidelines for the monitoring system, and the PICU staff has been trained to read algorithms provided by the system at the bedside so action can be taken immediately if a seizure occurs, even if it can’t be detected by observing the patient. In-depth evaluation of the data obtained from monitoring is conducted by a team of specially trained pediatric neurologists at Massachusetts General Hospital. The multidisciplinary team of specialists will study the results of continuous EEG monitoring in a wide PICU population to identify how frequently seizures occur among different diagnoses in the pediatric population, as well as how seizures affect outcomes. Once the frequency is established, the team will track how interventions, such as seizure medications, can benefit these patients and which of these interventions achieve the most favorable response.


Leader in Deep Brain Stimulation for Severe Movement Disorders
SeizureSurgery

Deep brain stimulation (DBS)—a method by which abnormal activity in brain circuitry can be modulated through surgically placed electrodes—is a treatment modality that has been widely used in the adult population for Parkinson’s disease and other movement disorders. More recently, this approach has been used to treat a range of other conditions in adults, including epilepsy, depression, obsessive-compulsive disorder, and Tourette’s syndrome. The modality is adjustable and can be increased, decreased, or even discontinued if needed, which is highly desirable in contrast to older, irreversible surgical techniques in which lesions were made in brain circuits in an effort to restore a more normal balance in movement disorders and other brain conditions. Because of well-established positive outcomes and safety profiles in adults, DBS techniques are now being applied to a wider range of conditions, and DBS is now FDA-approved for certain pediatric movement disorders, including some types of dystonia.

DBS surgery in the pediatric population is still fairly rare in the United States. However, Mass General has extensive experience with this treatment for a variety of adult conditions, and, for this reason, it has become a referral center for pediatric patients with severe, life-threatening movement disorders. Some of these children, who have not responded to efforts to control their dangerous movements, have been transferred to MGHfC from intensive care units at other centers, where continuous sedation has been necessary to prevent ongoing muscle breakdown. To effectively treat these rare patients, MGHfC has gathered a team of multidisciplinary specialists who are experts in DBS in the adult and pediatric populations. The team, which includes specialists from adult and pediatric specialties, including Emad Eskandar, MD, director of the Adult Stereotactic and Functional Neurosurgery Program, and other collaborators from neuroradiology, neurology, and psychiatry, is one of the first multidisciplinary groups in the country focused on DBS for children with severe movement disorders, and is using the experience it has gained to extend DBS treatments to children with other disorders. These include other movement disorders, such as chorea and ballismus, as well as more behavior-related conditions, in which the technology may be beneficial.

Learn how researchers at MassGeneral Hospital for Children are finding new treatments that advance pediatric care.


Improving Outcomes with Intraoperative Monitoring

To perform such complex brain procedures and protect brain function during surgery, Dr. Duhaime established a new team of collaborators to provide sophisticated intraoperative neurophysiologic monitoring. The team employs various electrophysiological methods to monitor brain and nerve function during surgery. Monitoring helps detect the potential for intraoperative injury in real time, allowing physicians to make immediate corrections.

A team of experts from an experienced pediatric intraoperative monitoring group along with experts in adult intraoperative monitoring at Mass General are preparing to study new approaches in intraoperative monitoring in children. While these collaborations focus on ways to improve the capacity for pediatric intraoperative monitoring of neurologic functions, advances may also improve monitoring in adults. The team plans to work with engineers to adapt the technology in ways that will improve the safety and efficacy of monitoring in children, and to study its effect on outcomes from surgery



Referrals

MassGeneral Hospital for Children is committed to making expert, state-of-the-art treatment available to children from across the community and beyond. The members of our network, which includes Newton-Wellesley and North Shore Children’s Hospitals, as well as hundreds of community pediatricians and pediatric specialists, work together to ensure that this goal is met.

Either families or physicians may make referrals to or inquiries about our Pediatric Neurosurgical Services by calling 617-726 3887.

Massachusetts General Hospital is consistently ranked among the top three hospitals in the country and its pediatric services in the top 1% in the nation by U.S. News & World Report Annual Guide to America’s Best Hospitals.We were the first hospital in the nation to attain Level 1 verification in Adult Trauma, Pediatric Trauma and Adult Burn. Our Brain Tumor Center receives referrals from medical centers around the world to care for children whose care is most challenging.



MGH Pediatric Neurosurgical Servicer - Wang Ambulatory Care Center - ACC-331 - Neurosurgical Service - Phone: 617-643-9175 - Fax: 617-726-7546 - Massachusetts General Hospital - 15 Parkman Street - Boston, Massachusetts 02114