Journal of neurosurgery. Pediatrics最新文献

{"title":"Applying Lean principles to pediatric neurosurgery: quantifying residents' perception of complexity of common procedures and concomitant effect on operating room efficiency.","authors":"Brannan E O'Neill, Yasmeen Elsawaf, Jamila Godil, Stephen G Bowden, Matthew K McIntyre, Jesse J Liu, Christina M Sayama, Nathan R Selden","doi":"10.3171/2026.1.PEDS25550","DOIUrl":"10.3171/2026.1.PEDS25550","url":null,"abstract":"<p><strong>Objective: </strong>Enhancing operating room efficiency while preserving resident surgical education remains a priority for teaching hospitals. Applying Lean principles to pair residents' step-level risk and comfort perceptions with step-level time may reveal training targets that reduce operative duration and improve safety. This study quantified the relationship between residents' step-level perceived risk or comfort and operative time during filum terminale lysis (FTL) and primary vagus nerve stimulator (VNS) placement.</p><p><strong>Methods: </strong>Attending pediatric neurosurgeons defined 11 FTL and 10 VNS placement steps. A 2-part survey captured step-specific comfort and perceived risk from junior residents, senior residents, and faculty members (for VNS placement, 11 junior residents, 10 senior residents, and 3 faculty members were surveyed; for FTL, 11 junior residents, 9 senior residents, and 4 faculty members). Responses were mapped to a risk matrix with a \"danger zone\" (high-risk score of 3-5 and low-comfort score of 1-3) and a \"safe zone\" (low-risk score of 1-2 and high-comfort score of 4-5). Step-level times were prospectively recorded across FTL (n = 16) and VNS (n = 24) cases. Analyses included the Fisher's exact test, Spearman correlations, and linear-by-linear tests for training-level trends.</p><p><strong>Results: </strong>Risk-matrix analysis showed significant junior resident-faculty member differences for both procedures, with no senior resident-faculty member differences. In FTL, significant junior resident-faculty member differences were observed for dural closure (p = 0.004). In VNS placement, junior residents more often labeled carotid sheath exposure, vagus nerve exposure, and lead placement as the danger zone (all p = 0.0027). Excluding closure, VNS placement demonstrated positive associations between perceived danger and both step time and share of cases (for junior residents, ρ = 0.73, p = 0.025; senior residents, ρ = 0.75, p = 0.020; faculty members, ρ = 0.58, p = 0.10). In FTL, no association was observed. Training-level trends showed increasing high comfort (≥ 4) with seniority across most steps (10/11 steps for FTL; 7/10 steps for VNS placement). Step timing highlighted skin closure for VNS placement (median [IQR] 1769 [1447-2304] seconds) and dorsal bony exposure (700 [427-1037] seconds), dural closure (932 [336-1387] seconds), and fascial closure (695 [563-828] seconds) for FTL as the most time-consuming phases.</p><p><strong>Conclusions: </strong>Combining step-level risk-comfort matrices with timing can yield procedure-specific teaching targets. In FTL, danger perception aligns with time burden, supporting focused coaching on dural closure and exposure; in VNS placement, the main time-intensive step is low-risk closure, which may yield areas for improvement via workflow and team-based interventions, while danger-labeled exposure/lead steps merit targeted supervision for safety. This Lean principl","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"259-269"},"PeriodicalIF":2.2,"publicationDate":"2026-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148176087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality of life and mental health in pediatric patients with low-grade CNS tumors treated with surgery alone.","authors":"Alexandra S Roak, Sage P Rahm, Sasha G Howell, Anil K Mahavadi, Emily A H Warren, Elizabeth M McRae, Avi Madan-Swain, Wendy Landier, David C Schwebel, Margaux Barnes, Brandon G Rocque, Sylvie Mrug","doi":"10.3171/2026.2.PEDS25392","DOIUrl":"10.3171/2026.2.PEDS25392","url":null,"abstract":"<p><strong>Objective: </strong>Pediatric patients with low-grade CNS tumors can experience an array of physical, cognitive, and psychosocial late effects, even in the absence of adjuvant therapy. It is unclear to what extent these late effects impact long-term quality of life (QOL). The aim of this study was to evaluate QOL and mental health in children with low-grade CNS tumors treated with surgery alone compared with healthy children and children with chronic illness.</p><p><strong>Methods: </strong>Medical records were retrospectively reviewed to identify children (age ≤ 18 years) who underwent surgical treatment of a low-grade CNS tumor (WHO grades I or II) without adjuvant therapy. Caregivers of enrolled patients (1-8 years after resection) completed a demographic questionnaire, the PedsQL Generic Core Scales, and the BASC-3 Parent Rating Scales. Scores were compared with published levels of QOL and mental health in healthy children and children with chronic illness.</p><p><strong>Results: </strong>Sixty-six patients and their caregivers enrolled in the study; the mean patient age at enrollment was 13.47 years, with a mean time from surgery to enrollment of 4.26 years. These patients demonstrated significantly lower patient-reported QOL scores compared with their healthy peers for all scales. The mean PedsQL scores showed that 58% of children experienced difficulty with school-related functioning, 49% fell at or below the age-appropriate cutoff for emotional QOL, 42% experienced decreased physical QOL, and 30% experienced social challenges. The proportion of patients with BASC-3 scores (n = 51) that met or exceeded the cutoff for at-risk or clinically relevant difficulties ranged from 8% (depression) to 14% (anxiety and attention, each).</p><p><strong>Conclusions: </strong>Children treated for low-grade CNS tumors with surgery alone can face challenges that impact their long-term QOL and mental health. Psychosocial functioning of these children should be routinely assessed at follow-up visits in neurosurgery clinics. Other providers and families should be made aware of the potential long-term consequences associated with low-grade CNS tumors treated with surgery alone. Similar to the psychosocial care recommendations for children with chronic illness, interventions should be developed for patients with low-grade CNS tumors to mitigate risk of impaired long-term QOL and mental health.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"146-152"},"PeriodicalIF":2.2,"publicationDate":"2026-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148175755","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pseudarthrosis in modern instrumented pediatric cervical spine fusion.","authors":"Emma Hartman, Bram Verhofste, Steven Staffa, Mark R Proctor, Daniel Hedequist","doi":"10.3171/2026.1.PEDS25339","DOIUrl":"10.3171/2026.1.PEDS25339","url":null,"abstract":"<p><strong>Objective: </strong>Instrumented fusion for management of pediatric cervical spine conditions has significant morbidity risk due to rare underlying pathologies, small anatomical dimensions, limited bony surface area, poor bone quality, and potential effects on future growth. Pediatric cervical spine fusions are often subject to pseudarthrosis, reportedly as high as 38%. The aim of this study was to evaluate a single institution's clinical experience with modern instrumented cervical spine fusion in pediatric patients to identify risk factors and management techniques for pseudarthrosis.</p><p><strong>Methods: </strong>Medical records were retrospectively reviewed for pediatric patients (age ≤ 21 years) who underwent instrumented cervical spinal fusion using current fixation techniques at a single institution between 2005 and 2023. Demographic and diagnosis characteristics, surgical details, and follow-up clinical and imaging findings were collected.</p><p><strong>Results: </strong>Overall, 150 patients (82 male, mean age at surgery 11.7 ± 5.0 years) were included. Underlying diagnoses included 51 patients with congenital deformity, 35 with instability, 24 with traumatic injury, 22 with tumor, and 18 with os odontoideum. The mean duration of follow-up was 5.9 ± 3.7 years. Twelve patients (8%) experienced nonunion, defined by a lack of osseous bridging (n = 6), screw lucency (n = 5), or both (n = 1) on CT or radiography. Eight patients in the nonunion group had an underlying syndromic diagnosis (p = 0.03), including 6 of 12 patients (50%) with Down syndrome (p < 0.005). The median time from index surgery to pseudarthrosis diagnosis was 11 months (range 3 months-3.07 years). Eleven secondary procedures were performed to address pseudarthrosis, with instrumentation revision in 10, autograft used in 6, and recombinant bone morphogenetic protein used in 7. A postoperative halo was used in 36% of revisions. One patient who underwent a secondary procedure for pseudarthrosis required a subsequent revision.</p><p><strong>Conclusions: </strong>Pediatric cervical spinal fusions had a pseudarthrosis rate of 8%. Syndromic patients, specifically patients with Down syndrome, have higher risk of nonunion and thus require counseling in this regard, as well as closer follow-up. However, syndromic patients with Ehler-Danlos and neurofibromatosis were not at increased risk of nonunion. The pathology and etiology of instability was not a significant contributor to pseudarthrosis. In most cases of nonunion, a single revision surgery was sufficient treatment.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"253-258"},"PeriodicalIF":2.2,"publicationDate":"2026-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148175725","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Spinal intradural epidermoid cysts in pediatric patients: illustrative cases and systematic review.","authors":"Sufyan Ibrahim, Kishore Balasubramanian, Beste Gulsuna, Andrew Jea, Nicholas Sader","doi":"10.3171/2026.1.PEDS25524","DOIUrl":"10.3171/2026.1.PEDS25524","url":null,"abstract":"<p><strong>Objective: </strong>Spinal intradural epidermoid cysts (sIECs) are rare, benign neoplasms comprising < 3% of intraspinal tumors in children. Their nonspecific clinical presentation and rarity often lead to diagnostic delays, particularly in the pediatric population. Authors of this study present 2 pediatric sIEC cases and conduct a systematic review of the literature to characterize the clinical features, management strategies, and outcomes of pediatric sIEC.</p><p><strong>Methods: </strong>A systematic review was conducted according to PRISMA guidelines, searching the PubMed, Embase, Web of Science, and Cochrane databases from inception to December 2024 for English-language case reports and case series describing pediatric sIEC with clinical, radiological, and follow-up data. Two illustrative pediatric cases managed at the authors' institution are also described.</p><p><strong>Results: </strong>Thirty-eight studies comprising 48 pediatric patients were included in the analysis, as were 2 cases from the authors' institution, yielding a pooled cohort of 50 pediatric patients. The median age at presentation was 7.5 years (IQR 9.75 years), with males representing 49% of the patients. Muscle weakness (78%), sensory deficits (38%), bowel or bladder dysfunction (38%), gait disturbance (34%), and back pain (30%) were common symptoms. Spinal dysraphism (48%) and infection (20%) were frequently associated with sIECs. Tumors most often involved the thoracic (30%) and lumbar (30%) spine, with 72% of cases spanning multiple levels. Gross-total resection (GTR) was achieved in 71% (34/48) of cases, and GTR significantly reduced recurrence (3% vs 29% for non-GTR, p = 0.03, OR 0.09, 95% CI 0.01-0.86). At the last follow-up (median 8 months), 64% (28/44) of patients were symptom free and 30% (13/44) experienced symptom improvement. The tumor recurred in 12% (6/50) of cases, and overall survival was 98% (49/50 patients). GTR with complete symptom resolution was achieved in both illustrative cases.</p><p><strong>Conclusions: </strong>In this first systematic review addressing sIEC in children, patients typically presented with progressive neurological deficits and the cyst was frequently associated with congenital spinal anomalies. Diffusion-weighted imaging was essential for diagnosis and surgical planning. GTR was associated with significantly lower recurrence rates and favorable neurological outcomes.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"242-252"},"PeriodicalIF":2.2,"publicationDate":"2026-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148175767","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Data-driven personalized surgical treatment selection for metopic and sagittal craniosynostosis.","authors":"Skyler K Palmer, Connor Elkhill, Ines A Cruz-Guerrero, Diego A Gomez, Marius George Linguraru, David Y Khechoyan, Phuong D Nguyen, Brooke French, Antonio R Porras","doi":"10.3171/2026.1.PEDS25397","DOIUrl":"10.3171/2026.1.PEDS25397","url":null,"abstract":"<p><strong>Objective: </strong>Although the choice of surgical treatment for craniosynostosis is based on patient age and phenotypic severity, there are no tools to objectively identify optimal treatment approaches. The authors present a quantitative study of how age, sex, and phenotypic severity affect the surgical outcomes of patients with midline craniosynostosis to support treatment selection.</p><p><strong>Methods: </strong>The authors collected pre- and postsurgical 3D photograms of patients with nonsyndromic single sagittal (n = 280) or metopic (n = 69) craniosynostosis, which they grouped into endoscopic strip craniectomy (ESC) or cranial vault remodeling (CVR) cohorts. The authors compared their surgical outcomes using the Head Shape Anomaly (HSA) index, Craniosynostosis Risk Score (CRS), and a novel Craniosynostosis Severity Index (CSI) that provides improved sensitivity to local malformations. Then, the authors quantitatively modeled the effect of age, sex, and presurgical severity on treatment outcomes and used their findings to create a decision tool to support treatment selection.</p><p><strong>Results: </strong>ESC and CVR improved all morphology metrics in patients with sagittal craniosynostosis (p < 0.001). In metopic craniosynostosis, ESC improved the CRS (p < 0.001) and CSI (p = 0.01), CVR improved the CRS (p = < 0.001) but not the CSI (p = 0.15), and neither ESC (p = 0.10) nor CVR (p = 0.83) improved the HSA index. The authors' model showed that ESC outperforms CVR in metopic and sagittal craniosynostosis before 3 and 5 months of age, respectively, as well as in nonsevere phenotypes of sagittal craniosynostosis before 8 months of age.</p><p><strong>Conclusions: </strong>The authors' quantitative results can support personalized surgical treatment selections for patients with midline craniosynostosis and constitute a needed step to reduce the variability in treatment approaches and outcomes.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"195-204"},"PeriodicalIF":2.2,"publicationDate":"2026-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148055041","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk stratification in pediatric dysembryoplastic neuroepithelial tumors: impact of molecular alterations, age, and extent of surgery.","authors":"Ahmet Harun Yaşar, Bahattin Tanrıkulu, Ayça Erşen-Danyeli, M Memet Özek","doi":"10.3171/2026.2.PEDS25637","DOIUrl":"10.3171/2026.2.PEDS25637","url":null,"abstract":"<p><strong>Objective: </strong>Dysembryoplastic neuroepithelial tumors (DNETs) are usually described as benign, but long-term data clearly show that progression is not rare. Molecular diagnostic techniques have revealed that FGFR1 alterations sit at the core of DNET biology. Importantly, FGFR1 point mutations are known to drive more aggressive behavior in several pediatric gliomas. Likewise, younger children often demonstrate poorer tumor control across multiple low-grade glioma subtypes. These parallels raise the question of whether similar risk patterns exist within DNETs. The aim of this study was to identify reliable predictors of progression in pediatric DNETs by analyzing FGFR1 alteration subtypes, patient age, and extent of resection in order to refine risk stratification.</p><p><strong>Methods: </strong>This retrospective study examined 37 pediatric DNET cases that were confirmed according to the 2021 WHO classification. FGFR1 and BRAF alterations were assessed using droplet digital PCR (ddPCR), and methylation profiling was applied in selected cases.</p><p><strong>Results: </strong>FGFR1 alterations were found in nearly 70% of tumors. The most striking finding was the markedly poor prognosis of FGFR1 point mutant cases, with progression rates exceeding 70%, whereas FGFR1 tandem duplications showed a much more indolent course. Age also emerged as a key factor: 45% of patients aged ≤ 10 years progressed, compared with only 5.9% of older children. Gross-total resection remained the strongest surgical determinant of long-term tumor control.</p><p><strong>Conclusions: </strong>DNETs are biologically heterogeneous. Subtotal resection, FGFR1 point mutations, and younger age clearly identify a higher risk subgroup with shorter progression-free survival. Considering the molecular profile, age, and surgical extent together provides a more accurate framework for clinical decision-making and follow-up planning.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"134-145"},"PeriodicalIF":2.2,"publicationDate":"2026-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148055182","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementing early posthemorrhagic ventricular dilation intervention in preterm neonates: does a standardized pathway improve outcomes?","authors":"Jennifer C Keene, Betsy Ostrander, Katherine Hartman, Suzanne Franklin Carbaugh, John R W Kestle","doi":"10.3171/2026.1.PEDS25574","DOIUrl":"10.3171/2026.1.PEDS25574","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;Posthemorrhagic ventricular dilation (PHVD) is a serious complication of intraventricular hemorrhage in extremely preterm infants, associated with high rates of death and neurodevelopmental impairment. Earlier CSF diversion might reduce adverse outcomes, but variability in practice persists. In 2021, a tertiary care center implemented a standardized multidisciplinary PHVD treatment pathway that emphasized standardized ventricular measurements and earlier thresholds for intervention. The aim of this study was to evaluate whether this treatment pathway reduced ventricular dilation and improved developmental outcomes in neonates with PHVD.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This single-center cohort study analyzed outcomes of neonates born between 2017 and 2023 who underwent PHVD intervention. Patients were dichotomized according to whether they were born before the treatment pathway was implemented (pre-pathway group) or after (post-pathway group). Data were extracted from the Hydrocephalus Clinical Research Network prospective registry and clinical records. Interventions included lumbar puncture (LP), ventricular reservoir placement, and ventriculoperitoneal shunt (VPS) placement. Ventricular dilation was measured using the anterior horn width (AHW) and ventricular index (VI). Developmental outcomes were assessed at ≥ 18 months using standardized development assessments and neurological evaluation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Overall, 104 patients were included; 59 in the pre-pathway group and 45 in the post-pathway group (10 of whom underwent only LP and were included only in an LP subset analysis). Following pathway implementation, high-volume LP was completed in 93% of patients. The median maximum AHW and VI greater than 2 standard deviations above the mean were significantly lower in the post-pathway group (AHW: 32 mm vs 26 mm, p = 0.03; VI: 18 vs 15 mm &gt; 2 standard deviations, p = 0.04). Among 74 infants with 18 months of follow-up, the primary outcome of death or severe cerebral palsy was reduced by 29% after pathway implementation (62% pre-pathway vs 33% post-pathway, p = 0.03). The multivariable analysis of all neonates demonstrated that larger ventricular size at VPS placement and at maximum ventricular dilation independently predicted higher odds of death or severe cerebral palsy, with a 9% increase per 1-mm increase in maximum AHW (adjusted OR 1.09, 95% CI 1.03-1.16, p = 0.006) and 14% increase per 1-mm increase in pre-VPS AHW (adjusted OR 1.14, 95% CI 1.05-1.24, p = 0.002).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;This study found potential for improved neurodevelopmental outcomes with pragmatic implementation of a collaborative standardized pathway for PHVD care. Pathway implementation was associated with reduced ventricular size at VPS placement, and smaller maximum ventricular size was a strong independent predictor of improved neurodevelopmental outcomes. These findings support earlier standardized PHVD i","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"153-163"},"PeriodicalIF":2.2,"publicationDate":"2026-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148055139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sports-related concussion laws in the United States in children and adolescents: an updated cross-sectional review of state statutes.","authors":"Khushi H Shah, Sebastian A Vargas-George, Caleigh S Roach, Victor M Lu, Toba N Niazi","doi":"10.3171/2026.1.PEDS25540","DOIUrl":"10.3171/2026.1.PEDS25540","url":null,"abstract":"<p><strong>Objective: </strong>Despite growing national consensus on the importance of cognitive evaluation and structured, graduated return-to-play protocols in sports-related concussion care in children and adolescents, it remains unclear how consistently these practices are reflected in state-level legislation. The authors aimed to evaluate the extent to which current state concussion laws in the United States incorporate evidence-based practices, particularly regarding cognitive testing and specification of qualified medical professionals for return-to-play clearance in these athletes.</p><p><strong>Methods: </strong>A cross-sectional review of concussion laws across all 50 states and the District of Columbia as of September 2025 was conducted. Statutory texts were abstracted for provisions addressing immediate removal from play, same-day return to play, use of baseline and postinjury cognitive assessments, implementation of graduated return-to-play protocols, and medical clearance requirements with specification of provider type.</p><p><strong>Results: </strong>All 51 jurisdictions have available state-level statutes regarding concussion care in children and adolescents. All require immediate removal of athletes with suspected concussion, with 74.5% basing removal on suspicion and 25.5% requiring signs or symptoms. Fourteen states (27.5%) explicitly prohibit same-day return to play, 2 (3.9%) allow it after concussion is ruled out by sideline evaluation, and the remainder do not address it. Medical clearance is universally required for return to play; however, only 6 states (11.8%) restrict clearance authority to physicians, while most permit broader categories of healthcare providers. Eight states (15.7%) mandate a graduated return-to-play progression, although protocols vary. Only Hawaii requires baseline cognitive testing, and Rhode Island recommends but does not mandate it.</p><p><strong>Conclusions: </strong>State concussion laws now universally mandate education, removal, and clearance before return, yet variability in coach training, return-to-play protocols, and cognitive testing exists. Aligning legislation with evidence-based standards is needed to ensure consistent protection for young athletes across the country.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"224-231"},"PeriodicalIF":2.2,"publicationDate":"2026-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148055164","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Neuropsychological profile in pediatric patients with brain arteriovenous malformations.","authors":"Adriane Oliveira Lima, Daniela de Souza Coelho, Raphael Wuo-Silva, Marcos Devanir Silva da Costa, Feres Chaddad-Neto","doi":"10.3171/2026.1.PEDS25591","DOIUrl":"10.3171/2026.1.PEDS25591","url":null,"abstract":"<p><strong>Objective: </strong>Brain arteriovenous malformations (bAVMs) are vascular anomalies that can cause significant neurological and cognitive impairments in children and adolescents, even in the absence of hemorrhage. These symptoms, especially the cognitive deficits, can significantly interfere with neurodevelopment and affect social adaptation and quality of life. This study aimed to characterize the neuropsychological profile of pediatric patients with bAVMs and to investigate associations between cognitive performance and malformation characteristics.</p><p><strong>Methods: </strong>This cross-sectional study included children and adolescents (6-17 years of age) with a confirmed diagnosis of bAVM treated between 2016 and 2023 at the authors' institutions. All information was obtained from medical records. Neuropsychological assessment was performed using the Brief Neuropsychological Assessment Battery infant (6-12 years) and adult (> 12 years) versions. The evaluated domains included orientation, attention, working memory, verbal fluency, memory, language, praxis, perception, and arithmetic ability. Results were compared to age- and education-adjusted normative data.</p><p><strong>Results: </strong>Seventeen patients were included in the study (58.8% female, age range 6-16 years); 10 had ruptured and 7 had unruptured bAVMs. Cognitive impairments were observed in 15 patients (88.2%), most frequently affecting working memory (digit ordering) in 7 patients (41.2%), memory in 5 (29.4%), arithmetic ability in 5 (29.4%), and praxis in 4 (23.5%). In all other domains, at least 1 patient exhibited some degree of impairment. Lesions located in noneloquent areas were associated with lower result performance in the memory domain. No significant associations were found with Spetzler-Martin grade, venous pattern, lesion size, lobe localization, or hemisphere.</p><p><strong>Conclusions: </strong>Cognitive impairments were common in children and adolescents with both ruptured and unruptured bAVMs, with the most frequent deficits involving executive functions, memory, and arithmetic ability. Lesion location, according to eloquence, was associated with poorer performance in the memory domain. These findings highlight the importance of comprehensive neuropsychological evaluation for guiding treatment planning and ensuring effective long-term follow-up.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"214-223"},"PeriodicalIF":2.2,"publicationDate":"2026-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148055172","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Utility of ophthalmologic evaluation for papilledema in pediatric emergency department encounters for shunt failure: a single-center retrospective study.","authors":"Muhibullah S Tora, Fanta Fofana, Kaleb Roach, Penelope Johnson, CeAnn Romanaggi, Isabella Pua, Matthew K McIntyre, Jesse L Winer","doi":"10.3171/2026.1.PEDS25230","DOIUrl":"10.3171/2026.1.PEDS25230","url":null,"abstract":"<p><strong>Objective: </strong>In shunted pediatric hydrocephalus patients, the potential for shunt failure is a frequent cause of emergency department (ED) presentation. The assessment of papilledema through ophthalmological fundoscopic examination (OFE) is an often-utilized adjunct evaluation in clinical workup to rule out shunt failure in patients. However, its utility in this setting has not been established in the literature. The objective of the present study was to investigate the association of papilledema with eventual shunt revision in ED encounters to rule out shunt failure.</p><p><strong>Methods: </strong>The authors conducted a retrospective, single-institution, cohort study of ED encounters with concern for shunt failure prompting neurosurgical evaluation in patients who underwent OFE from January 1, 2014, to December 31, 2021. Chart encounters were reviewed for baseline demographic characteristics, clinical characteristics, presence of papilledema, and interventions. The primary endpoint was need for shunt revision and intraoperative evidence of shunt failure.</p><p><strong>Results: </strong>A total of 594 ED encounters with concern for shunt failure were identified, and 98 encounters were included. Overall, 6 cases of papilledema were identified (6.1%), of whom only 3 were new or worsened (3.1%) compared to prior examinations. Twenty-six (26.5%) encounters resulted in shunt revision, while 72 (73.4%) encounters resulted in no revision. There was no statistically significant difference in baseline patient demographic characteristics, etiology of hydrocephalus, or clinical symptoms between encounters resulting in shunt revision or no revision. No significant difference was identified in the comparison of patients who underwent shunt revision versus those without revision with regard to the presence of papilledema (3 [12%] patients with papilledema vs 3 [4%] without, p = 0.19), performance of shunt tap (6 [23%] vs 9 [12.5%], p = 0.21), or prior shunt revisions (3.2 ± 3.9 vs 2.9 ± 3.3, p = 0.77).</p><p><strong>Conclusions: </strong>Among pediatric ED encounters with concern for shunt failure, ophthalmological consultation for fundoscopic examination and the presence of papilledema did not demonstrate a significant association with shunt revision. Additional prospective studies are warranted to assess the clinical utility of using OFE as part of the armamentarium of triage in acute shunt failure evaluation.</p>","PeriodicalId":16549,"journal":{"name":"Journal of neurosurgery. Pediatrics","volume":" ","pages":"172-178"},"PeriodicalIF":2.2,"publicationDate":"2026-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148055212","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}