Hello, everyone. Welcome back to the second day of our virtual meeting. I'm Ruth Bristol in Phoenix, Arizona, and I'd like to welcome you to our scientific showcase, which is our new virtual version of the poster session. Hi, everybody. Thank you for joining us. We have a wonderful meeting here so far, and we have the showcase session here. We divided it into eight different sections, and we have covered every possible entity in pediatric neurosurgery. It's exciting abstracts. We have wonderful people joining us and discuss different topics and wonderful moderators. So thank you, everybody, for joining us. Ruth? And again, the videos for the presentations themselves will not be played during this session, but they are available on your main screen, and you can watch those at any time. This will be a discussion session, and I must remind everyone to remember to go to one of those Remo conversation lounges to catch up, and then please visit our exhibitors. Enjoy the afternoon. Enjoy. Thank you. Okay. So welcome to our developmental anomalies panel, and we have some exciting abstracts to discuss this afternoon. I'd first like to take the opportunity to discuss an exciting abstract from Pittsburgh. We have our author, Eric Turibi, joining us here today, and this is a 25-year single-center retrospective analysis of surgically treated pediatric Kiari 1 malformations. Could you comment on the patients in your series who presented with hydrocephalus? Did this resolve, and how did you decide whether to treat the hydrocephalus first or the Kiari malformation first? Yeah, so that's a great question. So for many of them, we had patients, 40 patients who presented with hydrocephalus in this particular study. So most of these patients, which 22 of them were previously shunted prior. So these seven of them had endoscopic third ventricular stoma to begin with, and the others had VP shunting. So for most of these patients, we treated the hydrocephalus first, and that did not resolve. Then we went ahead and proceeded with the Kiari decompression. Okay, very good. And you noted that in the 8.5% of patients who required a repeat operation, could you elaborate a little on their age group and the reason for the repeat operation? Sorry, finish your question. Yeah, so the age spread for the patients when they were at repeat decompression was pretty varied, given that more or less in line with our patient population. But in terms of the reasons why many of them underwent a repeat surgery, an enlarging syrinx was the most common reason. We had 35 patients in total, as I mentioned in that presentation, who had repeat surgery. 19 of them was because of an enlarging syrinx. And then a further 12 was because they had recurrences, the accessional occipital cervical pain. So those are the two main reasons that we saw for people undergoing repeat decompressions. And then for the others, we had a couple of them who had ventricular symptoms, so dysplatonomia, and brainstem compression symptoms as well. And then we had a small minority who were not included on who had a transoral anterior resection as well. Okay, could you comment a little on the surgical technique for the tonsillar coagulation? Was this a peel sparing technique? Do you know much about the surgical technique used? I might not be able to cover it entirely completely because I mean, I got my data from reviewing the operative notes. But from my understanding, a lot of this involved, as you said, sub-peel coagulation. And we initially, for a very few minorities, some of them did undergo tonsillectomy as well. But for the tonsillopathy, it didn't involve coagulation. So purely. Okay, so a combination of techniques, it sounds like. Yes. Do you know if there was a preference for type of surgical graft that was used for the dura graft? Yeah, so good. That's a great question. Yeah. So about half of the patients we had were done using the collagen types. So we have DuraPair or DuraGen was the most common one that we used. That came to around a little over 40%. Following that, we have the pericranial autografts around 20% was the second most common graft that we used for durotomies. And then other subsequent ones followed up from those. Okay, very good. I'd like to make sure we have time to visit with all of our contributors today. So I'm going to move on to our next abstract, but thank you for your insights. We'd like to chat next with Dr. Andrew Hale from Vanderbilt. And your abstract is a Mendelian randomization enables causal inference of infectious disease traits on hydrocephalus and CSF shunt failure. So we have some questions contributed today, and I'd like to jump to that. But given the pathogen that causes meningitis can vary by age, how did you address this or consider this factor in your study? Yeah, that's a fantastic question. And it's something that we're actively looking at now. So the way we define our infectious disease diagnoses at present was through a classification called a fee code, which is the amalgamation of ICD codes as well as basic laboratory data. But now we have genetic information that's been linked to primary culture information, isolated bacterial, fungal, and viral pathogen culture information that's been collected from both blood and CSF. So we're now looking at performing Mendelian randomization on those individual pathogens, which has far greater complexity than the singular diagnosis of meningitis or sepsis. So that's under active investigation. Okay. So would you say that's kind of the next direction with your study? And how do you see that this might come into play in terms of clinical management coming forward? Yeah, I think when you get back these clinical microbiological samples and these reports, you can oftentimes see polyspeciation. And so while most infectious disease docs will obviously treat empirically across to potentially cover all of those pathogens, potentially all those pathogens aren't actually involved in causing the hydrocephalus or shunt failure itself. So then identifying those causative pathogens may enable identification and development of more targeted therapeutics. Okay. Very interesting. All right. Well, thank you for those thoughts. Our next abstract is from Randalyn Barnett from UNC Chapel Hill, and this is prophylactic anti-epileptic administration significantly reduces postoperative seizures in patients undergoing ETB-CPC. I failed to mention, I'd like to thank Dr. Lori Ackerman for her questions contributed to our session today. She asked today, have you considered that the choriplexis cauterization may be causing the increased incidence of seizures? And have you compared ETB alone to ETB-CPC in terms of patients experiencing seizures postoperatively? It's a great question. We did consider that. Just looking at some of the literature, there is a study that was done back in 2001. It was a small cohort of patients. It was only 27 patients, but they found that a 0% incidence of seizures after ETB alone. So we did think that combining that with CPC is probably the reason why we're seeing an increased incidence of seizures. But with our study, we did not compare that to ETB alone, but that's something good to look into. Okay. And I noticed that you had very successful rates of seizure control utilizing Kevra, but what was the duration of treatment and the standardized regimen that you guys used? Yeah. So what we did was, we started giving Kevra, I think about a year into the study. This was done from 2016 to 2020. And we started giving Kevra a little bit later into this particular study. But when we gave the Kevra, we decided to give a loading dose at the start of the case. And then we continued with maintenance dosing for seven days following the surgery. And then was it tapered off or just abruptly completed? It was abruptly completed. Okay. It is reasonable for a short course. Did you find that the postoperative seizures predicted a subsequent diagnosis of epilepsy or was it sort of an isolated phenomenon without long-term risk of seizures? We actually didn't do a long-term follow-up for this. So I can't attest with certainty that this may or may not have resulted in long-term epilepsy. Okay. And certainly even the occurrence of seizures in the short term is not a good thing for patients and can result in worse outcomes. Were you routinely evaluating patients with EEG postoperatively or only treating for clinically observed seizures? Yeah, we were only treating for clinically observed seizures. So we would only put them on EEG after we clinically observed one. And usually it was by an ICU nursing staff because all of our patients that we do eTB-CBCs on go directly to the pediatric ICU afterward. But that's a question that we've been thinking about doing another study on is putting all of our patients on these just to capture some clinical seizures that we may not be seeing. Okay. Very good. All right. Thank you very much for your thoughts. And we'd like to move to our next abstract. We have here today John Chae from Cornell and discussing revision Chiari surgery in young children predictors and outcomes. We have a question for you today is what criteria did you utilize for making the diagnosis of dysautonomia in young patients with Chiari malformation? Yeah, so that's actually a fantastic question. Because dysautonomia itself is a very complex disorder and the criteria for it is definitely not clear. So we were kind of looking at kind of a constellation of symptoms. So some of the patients had temperature dysregulation issues. Some patients had kind of unexplained GI dysmotility. And there were patients who had like tachycardia, kind of more like a POTS picture. So we're kind of looking at these different sort of clinical signs and symptoms to make this clinical diagnosis. But yeah, but there's always a caveat that this kind of dysautonomia is kind of a complex symptom complex to actually make a diagnosis of. Okay. And did the surgeries that required reoperation, the patients that required reoperation, were these surgeries with duroplasty or with bone only decompression or a combination of both? Yes, it was kind of combination. So it's different for different patients. So initially, I think about half of our patients out of our 40 patient cohort initially received without duroplasty and half that received it with duroplasty. So it kind of depended on what their initial surgery was. So people who didn't get initial duroplasty did end up getting duroplasty in their second surgery. But people with initial duroplasty, they either got a revision surgery with kind of redoing the duroplasty part. And there were patients who got fusion surgery. There's one patient who also got odontoresection. So you're kind of just kind of dependent on the pathology and kind of our suspicion as to what might be causing a lot of the issues. So it kind of varied for different patients. And in the revision surgeries, did you find bone regrowth at the site of prior decompression? Yeah, for some patients we did. So I think we found it for some of the younger children in our cohort. So some of these patients have bone regrowth that we first saw in the repeat MRI after their first procedure. So combining that with their symptom recurrence, we suspected that it was really this bone regrowth that was kind of causing this symptom recurrence in these patients. Did you find that was, you know, even within this young age group, all your patients were six years old or younger, did you find that more prevalent in the very youngest patients or evenly distributed amongst the ages in your study? Are you talking about like the bone regrowth? The bone regrowth specifically, yes. Um, I don't know if I can specifically comment on the distribution within our cohort, but I think I've seen it in sort of different ages, but all kind of within this sort of zero to six cohort. Okay. And did you find that there was any association of need for reoperation or symptom recurrence with the presence of syringohydromyelia, for example? Um, was there a higher incidence of reoperation in those who had a large syrinx or in what scenario did a patient, uh, would they be indicated for reoperation if the syrinx did not resolve? Yes, the syrinx was actually a very interesting factor to look at in our cohort. So it turned out that out of the 40 patients in this age group, um, we had 11 patients with preoperative syrinx before their first surgery, but actually none of those patients got revision surgeries. So all 11 patients with syrinxes, um, after the initial surgery with thoroplasty, um, their symptom, uh, all improved and their syrinxes all improved. So they didn't have to go through a second surgery. So our like revision cohort, um, none of them actually had syrinxes to, to, uh, evaluate. Okay. Interesting. Yeah. And, uh, Dr. Bristol is asking, would you suggest delaying surgery if reasonable, if their symptoms are not severe for some of the younger children to consider that they may not require reoperation if operated at a slightly older age? Yeah, I think that's a really complex, um, question to answer. I think it really depends on, um, the individual, the patient and, um, kind of the stories given by their parents and their guardians. Um, so I think it's kind of case by case scenario, but I think it's kind of important to bring up this topic of revision surgery kind of upfront, um, because, you know, revision surgeries can be pretty common in this age group. So if the symptoms are relatively mild, um, then I think we would advocate that it's reasonable to wait, um, for, for this age group. But again, I think it's really just dependent on the patient and the symptomatology of the patient. Perhaps the severity of symptoms and presence of the symptoms. Okay. Well, thank you. All great talking points. Um, I'd like to move on next to Dr. Andrew Floyd and discuss sociodemographic disparities in fetal surgery for myelomeningocele, a single center retrospective review. So you found, um, uh, racial disparity observed in access to, uh, fetal surgery for myelomeningocele. We know that maternal access to prenatal care and presence of prenatal care itself, as well as a timely diagnosis of myelomeningocele is a factor in accessibility to fetal surgery for myelomeningocele. We also know that maternal language and English language fluency can be related to access to fetal surgery. Were any of these variables captured in the NSBPR? Are those things that you can look at in this database? Good question. Um, to my knowledge, uh, the sort of mother tongue of the patient is not captured by the NSBPR. So whether they're native English speakers or not, um, but that has been a topic that has been brought up by a larger group looking at the NSBPR data is whether there are disparities in particular in, um, Spanish speaking patient populations. Um, but to my knowledge, the NSBPR is not capturing that data. The data that it is capturing was sort of the stuff that we, that we looked at in our study, which is, um, race and ethnicity, um, insurance status and zip code. And then the zip code can be used to, excuse me, to look at various things. Um, we can look at the median household income. And in this case, we also used a, um, a metric called the DCI, distressed community index, which looks at seven different variables. Um, but it doesn't cover things like, uh, parental education level. Um, unfortunately, um, it doesn't, uh, tell us whether the parents are living together of the patient. So there are some variables in the NSBPR that we just don't have. Mm-hmm. Uh, I think a very important question coming from Dr. Ackerman. She states, our institution has recently suffered the loss of one of our African-American chief residents in childbirth. And we have been hearing a lot about increased mortality and morbidity for this ethnicity and childbearing independent of something like prenatal surgery. Is it possible that there's increased risk in referring this group based on race that may be biasing referral patterns independent of socioeconomic status? I think this is a very important question to consider the maternal health status as a potential factor in referral. Yeah, it's a, actually a really interesting question is whether, you know, Black mothers would have a higher risk of fetal surgery if they have a baby with spina bifida. Obviously, that's a very challenging question to answer. Um, and even a challenging one to answer with the moms trial participants, you know, 92% of the moms trial participants were, uh, white. So it's a great question, uh, without a good answer, unfortunately. You, you suggest in your abject that fetal surgery centers should make an attempt to mitigate disparities in access to fetal surgery. What are your thoughts on what measures a fetal surgery center might take, uh, to take a step in the right direction there? It's a good question. Um, obviously a lot of families have to travel far for fetal surgery as it is taking them away from income producing labor, taking them away from family that can help them with the care of other children. Uh, and that's particularly stressful for patients of lesser means. So I, I think it, it means having funds available, uh, potentially to, um, help with travel, to help with lodging, to help with childcare, uh, and having, you know, dedicated social workers and the likes, um, to help mitigate the difficulties that can come along with having to travel, uh, often a great distance and away from home communities to have the procedure. Obviously that costs a lot of money, um, but, and this is already a very expensive procedure as it is, but, um, would be worthwhile given the benefits that are now being seen in the longitudinal studies in the mom's trial participants? I would say in our center having good access to social workers and Spanish language interpreters has been critical in providing support for especially our non-English primary language patients who are being considered for fetal surgery. Those are all great suggestions. So we have two minutes left in this session. I'd like to ask any of the other authors if you have any final comments or questions for each other towards the end of the session. Okay, so I'm gonna go around quickly and I'd like you to just give me a brief punch. If there's anything you'd feel I missed in your abstract that you'd like to highlight. Dr. Foy, since we're just wrapping up with you, anything else you'd like to highlight? No, just that I think that a larger look at the entire NSBPR for associated demographic differences in fetal surgeries are warranted. Great, and Eric Taribi? No, just, yeah, as John did say, I mean, Kerry is a complex disease and complex management. So it's good to hear that his findings are a little bit different from what we saw, but interesting nonetheless. And John Tse, any final thoughts? Yeah, same thing, same theme, like involving complex inter-care malformation. And there might be nuances in treating this condition and patients are very young. Randall and Barnett, final thoughts? I do wanna discuss something that we weren't able to fit into the abstract for this that we thought was pretty significant. Five of our patients who had seizures had EEG data that correlated with the seizures. And we actually found that 80% of them had seizures that lateralized to the hemisphere through which the endoscope was placed. So we found that to be really interesting. Very interesting, and might relate to ETV alone as well as ETV CPC. So something that might be good to follow up on. And Andrew Hale, final thoughts? Yeah, I think the one important aspect of our study was that this was done in patients in the U.S. And we know that the burden of post-infectious hydrocephalus is much higher abroad. And so if you look at a recent example, Steve Schiff's group just published a paper in Science Translational Medicine where they used 16S ribosomal RNA sequencing to identify one specific strain of a bacteria called Paini bacillus imbali. And that paper really demonstrates the complexity and the diversity of pathogens, and also the specificity at which pathogens can lead to disease. And so I think while we demonstrate a proof of concept in the U.S., I think this is a kind of more important question to answer on a global scale with the specific molecular mechanisms underlying infection and hypocephalus. So thank you very much. Certainly. Well, thank you everyone for joining us for this abstract session. We'll see you in five minutes in the next session. Please do not forget to join our remote conversation rooms and visit with our vendors in the exhibit hall. And that concludes our initial abstract session. Thank you. Hello, my name is Hassan Akbari and I'm a pediatric neurosurgeon at Penn State Health. I have the pleasure of moderating this section of outstanding presentations on functional anomalies. I want to congratulate each of the speakers on their outstanding work and their presentations. We'll go through each one with a brief summary of each of the abstracts, and then get into a little bit of discussion after that. So we'll start with Hannah Goldstein, who is currently a fellow out at Seattle Children's, whose project is entitled Initial Results from a Phase I Study of ABI-009 Nabsterolimus for Surgically Refractory Epilepsy. Hannah, if you want to give us a brief summary if you're... Sure, thank you for having me. So as I would say, most or all of you know, children with medically and surgically refractory epilepsy have increased risk of morbidity and mortality and limited to no options for improved seizure control. So this is a hypothesis-driven Phase I study aiming to evaluate the use of an mTOR inhibitor, ABI-009, in this patient population. mTOR inhibitors, as many of you know, have been used fairly extensively in the TSC patient population, initially for tumor control with sort of the additional benefit of epilepsy control as well. And so we've decided to expand this looking at, again, this is a Phase I study, so mainly just focusing on safety and efficacy, but with a secondary outcome of effectiveness as well. Our preliminary results are actually very encouraging. We found that it's safe and tolerated well in this patient population. And furthermore, several patients have actually had dramatic reductions in seizure frequency, even at a fairly low dose of the drug, which has led to actually an open label extension. We currently have three patients enrolled looking at optimizing dose and figuring out if there are specific patients we should be targeting. Perfect, that sounds great. I think one of the things that some of the folks were wondering is in terms of the patients that you have enrolled so far, it looked like you guys had about eight patients so far in the Phase I study. Do you have a sense for what kinds of seizure semiology each of those patients had and also what kind of surgery they had before starting up on this drug? Sure, that's a good question. I mean, it is a diverse patient population. And part of that, again, is because it was really designed as a Phase I study just to look at drug dosing and tolerability so it spans a gamut. They needed to have baseline multiple seizures a week to even enroll. And then every patient has undergone some form of receptive surgery. It's varied based, of course, on their individual pathology. So it's, I would say, a fairly broad patient population. Sure, sure. And then what overall is the kind of overarching goal in terms of the use of this medication? Is it primarily meant for something that's gonna be a lifelong medication that the patient will have to be on or something kind of temporary in the perioperative phase? If you can comment on that a little bit. Absolutely, so I think it's a little bit early to say with just our preliminary data, we actually have seen the way that the dosing is done is it's three weeks on and then sort of a rest period. And the patients who have completed the study, we've seen a prolonged effect in terms of seizure control before they then start to have an uptick in their seizures again, which would maybe suggest it would not need to be a lifelong medication. That being said, for these patients who kind of have no options, are on multiple AEDs at baseline, have exhausted surgical options, I think finding a medication that works, even if it means continually taking it is not a bad place to start. Sure, fair enough. We do have a question from Dr. Alexander for you as well. How is this mTOR inhibitor different from say serolimus or everolimus and is it an oral medication? I mean, substantially it's not that different. It's just the one that we happen to be using in this study. I think what's different about this study as compared to some other ones that are out there is it's a non-TSC patient population that we are looking at. And again, as we gather more data, we might find that there are, non-TSC is a very broad patient population. So we may find that it works well in certain patients. I know the mTOR pathway has been implicated in other types of epilepsy. So we may be able to hone in further, but at this point, that's kind of the key difference. Excellent. Thank you very much. I'm gonna move on now to Dr. Kennedy, who's out at, who had done some work with the folks out at Children's of Alabama on the variation in pediatric neurosurgery, stereo EEG practice amongst pediatric neurosurgeons in the U.S. If you could just give us a brief overview of your project, and then we'll get into a little bit of discussion. Sure, thanks. We had a lot of interest in a hypothesis that because stereo EEG is relatively new, and we thought many people in our field hadn't had formal training in it, and it's relatively creative, that there would be a wide variation in how exactly stereo EEG is practiced. And so we did a survey study. We got 61 pediatric epilepsy surgeons to respond from all over the country. So we felt like we had a pretty good sense, a pretty good breadth of what people are doing out there. It was 35 questions, so obviously I can't go through all the data in this format, but I would just touch on one of the things I found that we found most interesting, which was consistent with our hypothesis that there is quite a wide variety of strategies undertaken with the implants themselves. So everything from over a sixth of respondents were using a median initial implant of five to eight electrodes, while over a sixth were using 15 to 18. Similarly, there were several people who responded that they almost never, or that they almost always have bilateral implants, and about a sixth almost never have bilateral implants. And similar variation was noted in several of our questions. So we found that part very interesting. Obviously, with 35 questions, there's a ton of data to look at once it gets published, but that was kind of a highlight, I thought. Terrific. One of the questions that I had about your work was you focused primarily on pediatric neurosurgeons in terms of all this. Do you have a sense for what might occur with, say, epilepsy-trained neurosurgeons who do both adult and peds, and how they kind of differ in terms of the pediatric neurosurgeon's practice? Well, again, I can't tell you. We only had 18% of our respondents had done a dedicated epilepsy fellowship, which was, again, consistent with our hypothesis that relatively few people doing this, doing pediatric epilepsy surgery, had done a formal epilepsy fellowship. Fewer than half had any stereo EEG experience in their residency or their fellowship. So most people did not have formal post-residency epilepsy training, nor did they have stereo EEG experience in their training. So we couldn't, with only 18% of respondents having been fellowship trained in epilepsy surgery specifically, we weren't really able to dice out particulars about how they may differ in their responses. So you weren't able to tell necessarily with the folks who were epilepsy-trained if they had any kind of significant difference in terms of how they approached their practice? That's what I mean. Presumably more of them would have had stereo EEG training. You know, one of the underlying premises of our hypothesis that there was wide variation was that potentially people who kind of learn this on their own or take a course or just talk to colleagues may come up with their own more unique ideas about how it ought to be used rather than someone who's been through a training program where you do this every week and there's kind of a more standard way of doing it. Gotcha. Fair enough. All right. For the sake of time, just to make sure that we do get to everyone, I'm gonna move on to Robert Sickler's work. He's done some work out at UT Houston looking at the comparison of ROSA Robot and Stealth AutoGuide Robot Assisted Stereo EEG Implantation. If you can just give us a brief overview of your work and then we'll get into some discussion. Yeah, sure. So kind of touching on the same thing Dr. Kennedy was just talking about, there's a lot of variance in the novelty of SEG implantation with regards to various robot assisted techniques being adopted, namely the ROSA Robot, which is a more established one and the Stealth AutoGuide Robot. ROSA is a more rigid, floor-mounted robot that's shown to decrease off times without any decrease in safety or precision. And Stealth, likewise, has been shown to yield high procedural accuracy without any increase in off time or any adverse events related to its application. To date, however, no study has really conducted directly comparing these two within a single institution. So that was the goal of our paper. We conducted a retrospective review, 22 sequential pediatric SEG implantations and looked at the off time, time for electrode, registration, root-mean-square error for each robot. And we found that the mean registration, root-mean-square error was comparable and highly accurate for both robots. We also found that the mean operative time and mean time per electrode were both about twice as long for the AutoGuide Robot, suggesting that its off times were somewhat about, or significantly increased about double that of the ROSA Robot. We also found no complications for either robot and we also reviewed about seven other procedures for the Stealth AutoGuide Robot just to increase the strength of our comparison. Found no issues in terms of complications for any of those procedures as well, suggesting that both robots were highly effective, highly accurate and safe. Perfect. And so I know obviously both of these procedures were done at the same institution. Was there a particular reason for why one was used over the other, or was it just a switch that kind of happened through the course of time? So the ROSA had been used since I think about 2018 and just recently, early this year in February. I'm sorry. Yeah, February of the Stealth AutoGuide Robot was adopted. I don't have an exact answer for the complete logic, but we wanted to kind of see if that would provide more safety, more accuracy and see if we could, you know, figure out the best robot for these procedures. Fair enough. All right, we're gonna move on to Jerry Garcia Medrano who conducted some work out at Children's of Alabama and UAB looking at VNS stimulation in children with Lennox-Gastaut syndrome, a 20-year retrospective review. Just a quick overview of your study and then some time for questions. Yeah, thanks for having me. So as we know, LGS, it's an epileptic syndrome characterized by like a severe seizure burden that over time it becomes very difficult to control and its prognosis is like typically poor. So the purpose of this 20-year retrospective review was just to determine VNS efficacy, safety and tolerability and LGS patients younger than 19 years of age. And basically what we found was that our cohort demonstrated a response rate of 60% by five months of follow-up and there were no intraoperative complications during surgery, the adverse events. There were some patients that had a few adverse events where they were pretty mild and infrequent and not severe enough to warrant discontinuing the device. And there were a few patients that had infections but it was only a few of them and then a few also had revisions. A lot of them were due to battery depletion or end of natural battery life. So we didn't include those. We only included the four patients that had a malfunctioning VNS device. Perfect. And one of the questions that we had received was you showed us basically that there were different categories in terms of the frequency of seizures that patients had before undergoing VNS. Did you find anything like a dose response kind of a effect in terms of patients with more frequent seizures getting a better or worse outcome from VNS compared to say those who had less frequent seizures? No, we didn't really like look at that. That's not like a variable that we analyzed during the study. Okay. And were you able to look at kind of VNS settings through the course of time to see like how much the settings had to be titrated or if there was any kind of difference in terms of that? Yeah, initially we were. We were looking at like the stimulation parameters and like over time, like for example, like the adverse effects like the cough or like hoarseness or whatever, they like the increase in simulation parameters did like help resolve those over time or just like alone by themselves over time. Gotcha, perfect. And just to make sure that we have enough time to hear about everyone's talks, I'm gonna move on to Dr. Vijay Ravindra who while he was out at Texas Children's conducted a study on the magnetic resonance guided laser interstitial thermal therapy for pediatric periventricular nodular heterotopia related epilepsy. So if you could just give us a brief overview and then we'll have some discussion. Great, thanks Azan. I hope you guys can hear me okay. So while at Texas Children's obviously a world renowned epilepsy center, I was able to work with Dr. Curry on examining the role of MR guided laser interstitial therapy for PBNH related epilepsy. Our goal was to try to kind of describe this minimally invasive approach to a rare but problematic process. And historically open surgical approaches were carried with significant neurological morbidity and persistent neurological deficits. Now, so we looked at patients that were treated at Texas Children's with MR guided laser interstitial therapy for PBNH related epilepsy. Total of five children during the study period were reviewed and one of the children was treated twice. Overall, five of the six treatment sessions were preceded by stereotactic EEG phase two monitoring. Three children had unilateral PBNH and two had bilateral PBNH. Overall, we noted that 80% had an angle classification of less than or equal to three with a median angle class of three. Compared to adults, this is worse seizure outcome but given the population of patients and the burden of seizure disease, relatively good outcome in comparison to other treatment modalities. So definitely a technique that we think needs further study and we hope to report our findings soon to get this information out there. Terrific, thanks for that summary. And so looking at your data, you had gone over six patients and one of those patients ended up having a little bit of a complication in terms of just having the hemianopsia. Do you know if that kind of shed any light in terms of what cases in particular might benefit more or less from LIT therapy and kind of what can be done to maximize the safety and efficacy of LIT for this? Yeah, it's a great question. And I think as this technique becomes further refined, as I noted, three children had unilateral PVNH and two had bilateral. So the key to this is really localizing the epileptic genic center based on your phase two monitoring. So as I said, five of the six treatments were proceeded directly by stereo EEG and phase two monitoring to help really identify the seizure source. And I think drilling that down in patients with especially bilateral PVNH or unilateral PVNH is the strong kind of caveat to this technique. So making it safer as time goes on, I think is just really trusting your phase two monitoring and making sure that you can localize the lesion appropriately and really focusing on making your stereotaxy as accurate as possible. We use the ROSA technology at Texas Children's and those are things that we think will help make this technique further adopted in the future. Perfect. Question from Dr. Alexander was, did you have any technical challenges with LIT and PVNH due to the heat sink effect from the ventricle? Yeah, very good question. Interestingly enough, no, that was not something that we dealt with with the PVNH nodules. And I think the thing for that was when Dr. Curry plans these operations and trajectories, he purposefully tries to hit the most lateral aspect of the lesion to avoid any heat sink from the ventricular system. That being said on smaller lesions and in the future, that may be something of concern and may preclude treatment using this technique, but a very good question for sure. And did you have any patients that were treated for PVNH that did not undergo LIT to do some form of a comparative analysis between those who had LIT and those who did not? Yeah, only one patient. And so I think that's definitely something further that can be elucidated, but only one patient. So not much to compare it to. Okay, perfect. We did have a question for Dr. Kennedy. Will this survey lead to making recommendations regarding guidelines for training of future pediatric epilepsy surgeons using stereo EEG? And then did you happen to look at the rate of complications between those having trained with stereo EEG and those who did not? That's a good question. The second question is easier to answer, no. And that's because this is, we certainly had a few questions about complications. As with any survey, these are recollections. And so that's obviously a downside of doing survey research, but we thought that was the only feasible way to get a broad swath of what people are doing out there. So people would report what percentage of patients they thought had an asymptomatic hemorrhage or a symptomatic hemorrhage or an infection. They were all extremely low numbers. And also their case volumes per year. We just didn't think that it was reasonable to try to make some sort of calculation about rates of complications. We didn't feel that the data were strong enough to even add that into a discussion. I mean, in general, it was very low complication rates and surgeons generally felt that it was safe, but we didn't feel like it was appropriate to try to stratify risk based on experience. And then, sorry, what was the first question again? So it was, will this survey lead to making recommendations regarding guidelines for training a future pediatric epilepsy surgeons with EEG, stereo EEG? No, I mean, I think that it's, we came at this data purely agnostically and we don't place any value judgments on how people are performing it. We're curious, we had hypotheses that were confirmed like most people doing this work out there probably haven't done a formalized, a formal epilepsy fellowship, but that doesn't mean it's better or worse. To some degree, sometimes certain idiosyncrasies are institutionalized, right? And that doesn't mean they're correct. That just means that's how my mentor did it and that's how his mentor did it. And so that's how I do it. It doesn't mean it's right or wrong. And so, no, those are, we're remaining agnostic about value judgments. And did you happen to take a look at whether or not higher volume centers may be cutting back the number of electrodes that they're putting in, or if they're being a little bit less aggressive with time after say complications or things? Great question. In fact, it's the opposite. We did find statistically significant correlations between, there was a positive correlation between overall case volume per year and number of electrodes typically implanted initially in each patient. So actually it was the opposite. And our interpretation, obviously it's a soft interpretation, is that perhaps with experience, programs begin to feel, boy, I wish I had had more electrodes in that patient that we did. We would have maybe made, may have been more easy to make certain decisions about the patient's treatment surgery. So anyway, that was our interpretation of that. Yeah, I think that that makes sense. Certainly there's a lot of folks out there who, no one has really ever said, oh, I wish I put in fewer electrodes, but certainly many more say, I wish I'd put in more. So that is certainly interesting. And so I just wanted to again express that congratulations to everyone for doing such fantastic work. And just to remind everyone to use the remote discussion session to further discuss these topics and also visit the vendor booths if you can. Welcome everybody to the tumor session this afternoon for these abstracts. We have five really stellar abstracts and the authors are here with us today. So really looking forward to hearing about their work. And please don't forget to submit any questions you have about the abstracts as we go along and I will pass those on to the authors. So we are going to start with Rahul Kumar who did a really nice study on the clinical features, neurologic recovery and risk of postoperative posterior fossa syndrome. And I'm gonna ask the authors to give a brief one minute summary of their work before we get into some questions. So Rahul, do you wanna start us off? Yeah, sure. Thanks for the privilege and opportunity to share this exciting work with you all. The work we put together really focuses on what can be a dreaded complication of posterior fossa tumor resections, namely posterior fossa syndrome or cerebral mutism syndrome. And we utilize a prospectively designed study as part of an institutional trial cohort for pediatric medulloblastoma to utilize serial neurological examinations, not only to rigorously define the symptomatology of patients with PFS, but to try to uncover the spectrum of disease as far as manifestations of that syndrome goes. Additionally, one of our key tasks was attempts to define or uncover intrinsic risk factors within the patient population and tumor characteristics. And so we were able to recapitulate expected findings where midline tumors, particularly those in the non-signing hedgehog subgroup were particularly prone to the development of this posterior fossa syndrome. And then also exploring the role of surgical resection and how surgical injury can be a specific factor that influences the development of this. And we try to take the point that there are certain modifiable risk factors in surgical resection that we can, as surgeons try to mitigate injury to critical neurovascular structures in the region, which are really factors that are built around surgeon experience in our opinion. And so we hope that this work generates some discussion. Be happy to take any questions. Great, thank you. You established that there was increased risk in patients in a few categories. One of those was older age. How did you define older age or did you see a general linear trend through your patient population? Yeah, we explored the data in both dimensions actually with age as a continuous variable as well as dichotomizing it, I think around seven or eight years old. And we saw an increased risk amongst older patients. And I think the working hypothesis is likely related to the fact that neuroplastic potential might be decreased in older patients and their ability to recover from the insults that really are instrumental in kind of setting off posterior fossa syndrome after resection might be lower than patients who are younger. Okay. You also noted that one of the risk factors was primary surgical treatment at a low volume surgical center, which you defined as less than 500 patients a year. And one of the measurable differences between patients treated at those centers was the increased rate of CSF diversion. Did you also look at postoperative injury findings such as edema within the cerebellar vermis or brainstem or postoperative clinical outcomes that were unrelated to the posterior fossa syndrome? Unfortunately, as part of the trial protocol, we didn't have universal access to all the immediate postoperative imaging. So we were unable to really discern the degree of true surgical injury. And I think that area of study is something that's really going to be critical in the past moving forward because there's likely a discrimination between true surgical injury and the pathogenesis, pathophysiology of true posterior fossa syndrome. But I think what we did note is that those patients who had serious injury or over resection, you could say, of tumor leading into damage to neurovascular structures, including the superior cerebellar peduncles and other critical brainstem structures was definitely seen in patients who had a really severe presentation of PFS. Okay. You also talk about tractography a little bit. How do you feel that tractography could improve surgical technique for these posterior fossa tumors since that's a potentially modifiable element? Yeah, I think tractography, advanced imaging, and really are tools that an experienced neurosurgeon can utilize in surgical planning and to guide their resection in attempts to avoid damage to critical white matter structures that are emanating from the cerebellum and into the brainstem. Additionally, I think surgeon experience is something that's very difficult to define. We used center volume as really a surrogate and proxy for this really to explain or to put out the notion that surgeons that might be operating at lower volume centers might have a little less experience and less knowledge of some of the technical nuances that can go into really conducting a truly safe and effective resection. Because obviously, extended resection can play an important role in disease staging and prognosis for these patients. But circumferential dissection and identifying a clean plane around the tumor while being aware of surrounding structures, minimization of retraction, and avoidance of use of fixed retractors I think are really key as modifiable risk factors. Okay. All right, we're gonna move on. Thank you. We're gonna move on to Dr. Mohamed Fouda, who's going to give us a brief synopsis of his work on management strategies for recurrent pediatric craniopharyngioma. Dr. Fouda, who, disclaimer, I mentored him for some of this work, although he did not really require much mentorship. So, Mohamed, go ahead. Yeah, thank you, Dr. Berlin. Of course, your mentorship was really very helpful, so thank you so much. And actually, I think through the past three years I've been working on the craniopharyngioma for a real interest on the craniopharyngioma because I believe it's a benign lesion in a very malignant location. And the problem with the recurrent craniopharyngioma that usually, like the vast majority of the patients, are asymptomatic, and usually there's only radiographic recurrence for almost 90% of the patients based on our experience at Boston Children's. So we try to focus on the predictors of the recurrence at the early beginning, and we figured out, like, the fine calcification and the external resection could be very significant risk factors for the recurrence. And then we looked at, like, the predictors of the appropriate timing of intervention at time of recurrence. So we try to avoid any unnecessary surgical intervention or adjuvant radiotherapy or adjuvant chemotherapy for those patients if it's not necessary. So we avoid any burden for the families or for the patients themselves. So based on this, we looked at all the parameters, like the demographics, the tumor characteristics, like either cystic or solid, or the external resection, gross total resection, or subtotal resection alone, or subtotal resection followed by adjuvant radiotherapy. And then we looked at all these parameters and the univariate analysis and the multivariable logistic regression analysis. And we figured out, like, before the production of recurrence, the fine calcification and subtotal resection alone are associated with the highest rate of recurrence in comparison with the external subtotal resection with adjuvant radiotherapy. And the other thing that we looked at, like, that we figured out, like, the increase in the tumor size at time of recurrence in comparison to the initial tumor size at time of initial diagnosis could be used as a predictor of the appropriate timing for intervention. So based on this, we developed an algorithm for the management of craniopharyngioma time of recurrence, and we use this increase in the maximum dimension of the tumor size as a predictor of the appropriate timing. So if there's an increase more than 30% of the initial tumor size at time of initial diagnosis, this indicate, like, immediate intervention, even if the patient is clinically asymptomatic. And if the increase is less than 25%, then it means, like, we can follow up on this patient without any surgical intervention. And if there is any increase between 25% and 30%, we can follow up on this patient with another MRI in three months. And if there is increase more than 5%, then it's an indication for intervention. We believe that based on this algorithm, we can, first of all, like, stratify patients into categories, like high-risk categories, like low-risk categories, and medium-risk categories. So for the high-risk categories, which more than 30%, we believe, like, it's an indication for immediate intervention. And for the low-risk, you can wait and just follow up on them. And for the medium-risk, we can do the MRI after three months, and if there is an increase in the tumor size more than 5% in comparison with the initial presentation at time of recurrence, then we can do this, we can do the intervention at this time. Great. So I'm, we're running very behind already, so I'm just gonna briefly ask you, you know, for the most part, decisions on recurrent disease are made by consensus decision in a multidisciplinary discussion. It's nice to have a little bit of evidence like this. However, do you, what situations would you find it appropriate to deviate from an algorithm like this? For instance, location of the recurrence or age of the patient or, you know, neurologic status of the patient? Yeah, actually, this is a very good question. So I believe this is like a, we believe that this algorithm could be a standard. However, like exceptions could be made anytime by even the surgeon or the oncologist or even the family themselves. So in case of like a symptomatic patient with any symptoms of increased intracranial pressure or like associated hydrocephalus that needs intervention, I think at this time we can just like disregard this algorithm and go with the clinical findings. And the other thing, like if there is a consensus between the neurosurgeon and the neuro-oncologist that this patient, for any certain reason, maybe either like the tumor is operable and we can get the tumor out, like by gross neurosurgery and the safer section, then we can like, you know, disregard this algorithm. I believe this algorithm just made for, to standardize the, like the healthcare, like service delivered to the patient, especially for centers that they don't have like that much experience to like manipulate the findings and such things. Yeah. Well, really nice work on this. And we're going to move on. So the next abstract and work was performed by Peter Adedarma, and it was on mutational and gene expression landscapes of two novel sonic hedgehog medulloblastoma sub-subgroups in children under five years. So Peter, I'm going to ask you to give a very brief synopsis and we'll hopefully have time for questions. Okay, sure. Thanks. So my research begins with the issue that there's a current discovery of heterogeneity in infant medulloblastoma that is defined in medulloblastoma under five years. But, and this group is clinically significant, but we currently not yet understand the biology behind them. And this group, namely the sonic one and sonic two, and the sonic one has a poor progression-free survival in comparison to the sonic two. And because of that, our research are focused to develop the mutational and gene expression landscape, and also develop an immunohexochemistry assay of these sub-subgroups. And what we did is that we first collected three cohorts, which is our NUCCA cell cohort that consists of RNA-seq and also mutational datasets. And also the NORTH cohort that consists of mutational datasets, and also the CAVALI cohort that consists of expression or datasets. And then we conducted the mutational validation, and then we also conducted the gene expression analysis, gene set enrichment analysis, and in genetic pathway analysis. And in the end, we also developed the immunohexochemistry assay to develop between these two novel sub-subgroups. And what we found is that at mutational level, these two sub-subgroups are different, in terms that the sonic one has exclusivity of KMT2D mutation, while at gene expression level, there's 80 genes that is significantly differential expressed between these two sub-subgroups. And the sonic one, the group with the poorer prognosis has enrichment in gene set and pathway that is related to the stemness for potency, and also neuronal proliferation. While the other group, the sonic two, that has a better prognosis has enrichment in immunologic gene sets and also pathway. And what we also found is that we developed the immunohexochemistry assay that can distinguish these two sub-subgroups. Okay, great work continuing to refine the molecular stratification of medulloblastoma. How do you feel your work could be leveraged for potential treatment options? For instance, is there a role for say KMT2D targeting? Okay, so what we found in our center is that in medulloblastoma under 5 years, there is only one predictor of overall survivor, which was the NMN or LCN classic pathology, where the subject with the NMN pathology has a better prognosis, and in those sub-subgroups with the NMN pathology, the only way to predict the progression for survival, is it better or is it worse, is these novel sub-subgroups, and the clinical significance of this finding I think is mainly to differentiate between these two sub-subgroups within the NMN under 5 years of medulloblastoma, so that we can decide which group that we can hold the craniospinal irradiation, and or which group we can proceed with craniospinal irradiation. Okay, thank you. Really nice work. We're going to move on to Dr. Virendra Desai, who's going to talk to us about predictors of seizure freedom in pediatric low-grade gliomas, and is going to give us a very brief synopsis. Yeah. Thank you. You got my name exactly right. So I inherited this project from Dr. Jeffrey Raskin, Andrew Jay, it's been great, looking at predictors of seizure freedom in low-grade gliomas. It's well known that low-grade gliomas have a very high seizure rate, even more so than high-grade gliomas, and epilepsy can really take a toll on patients and their families, so our goal really should be not just an oncologic resection, but also an electrogenic resection, and just so we can appropriately counsel patients and their families, it'd be nice to identify what specific predictors there are for them attaining seizure freedom. So we looked at our database of all low-grade gliomas that were resected in the supertentorial space, and looked at several different variables that were significant in an adult population, and we actually found some interesting results that were not in line with the adult studies, the main one being that the extent of resection was not a significant predictor of attaining seizure freedom. We think that several possible reasons could be that we did not specifically define seizure freedom as six months or 12 months post-operatively, as many other adult studies have, we looked at it long-term, over four or five years, and the others, we did not really specify what a subtotal resection was, and there are several studies out there that say it's not really a black and white picture, it's an extent of resection that really matters, and even a 80-90% subtotal resection can be significant. So real quick, I'll just say what we did find important, basically those people that required anti-epileptic medications, as expected, had a higher seizure burden, those that had a recurrence had a higher seizure burden, and those who presented with seizures had a higher seizure burden. So I think, obviously, more analysis is necessary, and we're currently undertaking that, but this gives us some basic groundwork on how to properly counsel our patients. Thanks. It's certainly interesting that gross total resection wasn't a significant factor. Do you think that ECOG could play any role here, and is that something you looked at, especially for the cortically-based low grades? We did. We only, at the initial analysis, had the ECOG data for about half of the patients, so I hadn't included it, unfortunately, on the presentation, but we did not see any significance using ECOG without it. Okay. Really interesting. All right, we're going to move on to our last abstract, Dr. Cody Nesvick, whose work is the phenotypic and epigenetic impact of SMARCV1 restoration in ATRTs. So, Dr. Nesvick, do you want to give us a brief synopsis? Yes, absolutely. Thanks, Dr. Byrd. So as you mentioned, I work in Dave Daniels' lab, and I study ATRT, which is a rare embryonal tumor in kids. It's very unique amongst cancers, as is all rhabdoid tumors, and that is genomically much simpler than what we're used to seeing. The only recurrent genomic event is a biolelic loss of SMARCV1, so these are very difficult tumors to study because they're so rare, but we decided to leverage their genomic simplicity to see if we could unravel some epigenetic mechanisms of disease that contribute. So SMARCV1 is a member of this large complex called the BAF chromatin remodeling complex, and so we re-expressed SMARCV1 in a library of ATRT cell lines of multiple molecular subtypes and studied the phenotypic and epigenetic changes that follow from that. In the abstract presented here, we have transcriptional and ATAC-seq data, which define chromatin openness, and we did this in an effort to determine transcriptional regulatory networks that are differentially regulated in SMARCV1-absent and SMARCV1-present cells, and basically we found that there are distinct up- and down-regulated transcriptional regulatory networks in SMARCV1-present and absent cells, and our long-term goal is to leverage this into something that's translationally relevant to patients. Okay, really, really nice work emphasizing the importance of the epigenetic factors and influence for these tumors with low mutational burden. To what degree do you think an in-vitro model alters the epigenetic information? I think that would be very interesting to be hearing about your potential future trajectory with this. Yes, we know that, you know, putting cells in the dish certainly changes their epigenetic landscape in a not insignificant way, so much so that in some cell lines, the methylation signature that is used to characterize so many tumors nowadays is lost just by putting them in a dish or sometimes even in an animal. We know that there are a lot of key enhancer marks that are retained in vitro. These can be matched up to ATRT patient specimens, so even though they do not accurately recapitulate patient tumors 100 percent, we know that there are a lot of key enhancer marks that are retained in the in-vitro condition. There is some variability between cell lines depending on culture conditions, depending on molecular subtype, and in an effort to circumvent that, we have a library of about nine cell lines that we work with and look at only the recurrent changes to analyze our data. Okay. Well, I'm sorry to wrap this up late, actually, but wrap it up. A lot of really fascinating work here and really commend all of you for these abstracts and the work that you did. So a reminder to everybody that if you have questions or want to continue these conversations, head over to the RIMO Discussion Lounge, and thanks for joining us. Hi, everyone. Thanks for joining us. We're now in the socioeconomic section. We're just going to do a quick summary by each of the authors, and then we'll move into questions. We're going to try to be a little bit more succinct so that we can try to stay on time. So first up, we have Catherine Zimmerman. She's a medical student at University of Alabama, Birmingham, and her project was entitled Comprehensive Policy Recommendations for the Treatment of Hydrocephalus and Spina Bifida in Low- and Middle-Income Countries. Hi, everyone. So my name is Catherine. I'm excited to be here today to share with you our project on our Comprehensive Policy Recommendations. So this was a project housed out of Harvard's Program in Global Surgery and Social Change, and essentially what we sought to do was taking the NSOAP framework, which is a National Surgical Obstetric and Anesthesia Plan framework, and to create policy recommendations for the treatment of hydrocephalus and spina bifida. And our hope is that this framework that we've created can be adopted into real NSOAP plans that over 30 countries are currently working on. All right, so the first question came from Dr. Bristol, and she was interested in what was the process at arriving at all these recommendations, because it seems like there's a lot of different processes and a lot of different recommendations in different subgroups. Yeah, so I'd say the first thing is that these are totally comprehensive recommendations, and so they extend beyond just neurosurgical care, and as you can see, if you kind of look at our video, you'll see they include a ton of different aspects of care. I would say we did two different things. So the first, we wanted to take the NSOAP framework, and so this included making recommendations for infrastructure, workforce, service delivery, financing, information management, and governance. And then what we decided to do, since we wanted these recommendations to be comprehensive, is that we kind of designated phases of care. And so we did pre-hospital, surgical systems, rehabilitation, follow-up, and transitional care. And then we took that NSOAP framework, and for each of these phases of care, we came up with recommendations. Okay, awesome. And another question from Dr. Boop was, since nutrition or poor nutrition leads to such high surgical complications like infection and wound breakdown, how can we incorporate nutritional status and supplementation into their care? Oh, interesting. So I think that's a really good point, and something that I can bring up with all the collaborators. This is a very large project, we had many people involved, and I think that's a really good point. We probably can include it in maybe our kind of follow-up and transitional care, and also kind of our prevention and pre-hospital care. That's a really good suggestion. Great. We're going to move on now to Gabrielle. Gabrielle Johnson, she's a med student at Washington University of St. Louis, and her project is entitled Representation of Women in the AANS and CNS Pediatric Section and Annual Meetings. Hi. Thank you all so much for having me. This project kind of is something that's really important to me, and as a female who's interested in neurosurgery, and I noticed that in pediatrics in particular last year at the meeting, that there was a higher representation of women, so we wanted to look at kind of what the numbers in the hard data were for the AANS, CNS section, and we felt that pediatrics does have a higher representation of women in general, as well as in some of the meetings as speakers, and as well as the executive board. However, females are still kind of underrepresented in things like panels and abstract last authors, so hopefully with this information, we can continue kind of to increase representation in pediatric neurosurgery and neurosurgery as a whole, now that we have kind of concrete numbers to look at and concrete numbers to shoot for. The data that you presented was very interesting, and I was curious, actually, if you looked into the data or to the proportion of submitted versus accepted abstracts by female authors, as opposed to just the ones that were presented. We did not. We were using abstract books from the conferences, but that's definitely something that we could look into. It seems that would be a very interesting number to look at as well. Okay, and Dr. Boop asked whether or what we can do as neurosurgeons and as a specialty to make neurosurgery more attractive to female applicants. I mean, I can only really speak right now in personal experience, but I think that one thing that's been really important to me is having mentors, and female mentors in particular at WashU, Dr. Strehle, who is the PI on this project. She is the only female attending, so seeing her here has been really inspirational to me, and having someone to go to about what it's like to have a family and manage neurosurgery and residency and such. That's been really important. So that's definitely one avenue that I can see kind of making more robust and connecting female medical students with more female faculty. Great. Well, thank you, Gabrielle. We're going to move on to the third abstract. This is by Dr. Aaron Yango-Khan. He's a neurosurgery resident at Vanderbilt University, and his project is entitled The Cost of Concussion in American High School Football. Thank you. So this project came about a couple of years ago when we actually met with several high school coaches, athletic directors, and parks and recreation directors in the Middle Tennessee area, who their biggest concern around concussion is when is it cost effective or is it at all cost effective to get new helmets? Which seems like a very simple question, but it's actually, we found out over the subsequent two years, harder to get an answer to that practically. So the first step in that is actually understanding what does it cost to have a concussion, and then we can go and understand what sort of preventive measures are cost effective. So what we did was we just looked at the last three seasons of high school football players that came to our clinic for initial concussions, and we tracked the direct healthcare costs of all of those players. And then our analysis focused on, one, what were those costs, and that was about $800 on average per player in direct healthcare costs, and then two, what factors or clinical factors really drove up those costs? And perhaps not surprisingly, what we hypothesized was that those with persistent post-concussion symptoms over a month had a much higher cost than those that did not have persistent symptoms or post-concussion syndrome. Also, just the initial symptom score, so when players came to the clinic, how high their symptom burn was at that time predicted how much cost they would have over the course of their concussion episode, and that was almost exponentially related. And so anyone that has over a score of 20 when they're coming to the clinic could be expected to have much higher costs. And so this is kind of the first step in really understanding, in football at least, how do we make things cost effective? So is vestibular therapy or physical therapy cost effective? Who should get that? Is upgrading your helmet cost effective? If a concussion only costs $800, is it worth spending $1,000 on a helmet, and how do we start thinking about those questions? Great. There was something surprising about your results that surprised both Dr. Bristol and myself. One was that a prior concussion was not associated with a higher cost. Did you look at the timing between the two concussions or any other factors that might have kind of mitigated that difference? I agree. I think part of that, the reason that we did not find an association there is the relationship between prior concussions and then the symptoms in the given concussion. So I think that if you have two players, one that's had several concussions, one that hasn't had any, the symptom burden in the player that has a number of concussions will be higher. And so I think the effect of that is really panning out in the initial symptom burden. The other difficulty with the prior concussion data is that we made a decision to dichotomize it rather than looking at a continuous variable. Some players report, say, 15 concussions when you ask them in clinic, and you don't really know when those happened, how did they happen. They're a little more fuzzy on that, whereas other players can easily say, in the spring lacrosse season, I had a concussion six months ago. And so trying to figure out how to put all of that data together and make it digestible, we found that it was, in this case, the best way to do it is just dichotomize whether they had had a concussion history. I think going forward that we're trying to do a better job at collecting prior concussion data and understanding the time since, probably more recent concussions matter more. So understanding prior concussion within the last six weeks or six months should play into this as well. It makes sense. All right. Thank you, Dr. Yango-Khan. We're going to move on to the fourth project. This is by Jessica Burns. She's a medical student at Indiana University, and her project was standardization of CSF shunt valves in pediatric hydrocephalus and analysis of cost, operative time, length of stay, and shunt failure. Hi. Thank you. Our name is pretty telling on our paper, so pretty much what we looked at was we wanted CSF shunts are one of the most common procedures performed in pediatric neurosurgery, and with multiple studies, we weren't able to find a superior shunt valve. So we aimed to examine the impact of a shunt valve standardization at our institution to determine if there was a difference in surgical cost, operative time, and short-term post-op shunt failure. So it was pretty straightforward. We did a retrospective analysis at our institution of all the new CSF shunts that were placed and revisions over a year time period, and then we had a transition phase where we had all the neurosurgeons use one programmable and one fixed-pressure shunt valve for a whole entire year, and then we compared those two groups. And what we did find was that it does significantly decrease the operative cost of CSF shunt valves, but it does not increase operative time, and it doesn't increase post-op shunt failure. Great. One question that I had was, how did you get neurosurgeons to agree upon two different shunt valves, and what did you determine or how did you guys determine which shunt valves to include? So I can't exactly answer to the first part, but I imagine it was quite difficult. I know that they had weekly meetings where they talked with not only the neurosurgeons but with the NPs and kind of decided what the shunt valves were that everyone agreed were the ones that they were most comfortable with. I know cost, and a lot of people had this question when they were reading our paper, cost was not a factor when they were picking it, although that's something we ended up looking at, but I think they went off what they were comfortable with and all discussed it with the NPs and everyone that's been working with it at our institution. And the group of surgeons did change, which is one of our limitations, so the surgeons that were in the pre-standardization group were a little bit different than the surgeons in the post-standardization group. Gotcha. Another question that we had was, what exactly went into the cost that you measured? Was it amount of money billed? Was it the amount of total hospital cost? I think it was the amount of money billed. Okay. Gotcha. And then I had one other question. Why was it cheaper to have a standardized option versus letting the surgeons choose? I'm looking at that. I think it was more that when they were picking a shunt that everyone was familiar with, there was a lot less revisions, a lot less time spent in the operating room, which all goes into reducing that cost. Gotcha. Okay. The last question I had for you was, I noticed that there was a slight difference in the revision rates, not necessarily the malfunction rates or the infection rates, but the revision rates, which was not statistically significant. But I was curious if you had patients who crossed over from the non-programmable type because of either too much or too little drainage. We did. We did have patients cross over, and I believe we ended up not using those patients in the final. Gotcha. All right. Well, thank you, Jessica. Thank you. We're going to move on to our last project. This is from Pius Patel. He's a medical student at Vanderbilt University, and his project was titled, Rural and Urban Disparities and the Effects of Institutional Care Volume for Pediatric TBI Outcomes. Thank you all for your time, and I appreciate the platform to share our study here. As Dr. Renker mentioned, our project was essentially chasing the question of, how well are pediatric TBI patients being triaged to high-volume care facilities? We know over the past couple decades, we've had this shift in EMT routing to cluster high severity injury at experienced level one trauma centers. We also know that kids that take longer to get to the hospital have worse outcomes. Our idea was that rural kids that live farther from these hospitals might have these two factors in conflict. What we did was we took data from the National Inpatient Sample from 2012 to 2015. We segmented the pediatric TBI population into rural and urban, we tried to see if annual volume of pediatric TBI cases at the treating hospital affected clinical outcomes after adjusting for socio-demographics, severity and type of injury, and then kind of hospital characteristics. What we found was a very, very happy negative result. We found that for mortality, inpatient medical complications, and a discharge disposition in a proxy for a functional outcome, we found that annual volume of pediatric TBI cases did not affect outcomes for either population. We did see on univariate analysis, however, that rural dwelling patients in general had higher measures of injury severity, had worse outcomes overall, so there's kind of something else that we can still do here as a society and as a medical institution to try and fix this gap. Some of the things that we think that could be next steps, you know, the identification of what is a severe injury, so we saw that rural patients were disproportionately vehicular mechanism and higher grades of injury severity, so how can we, you know, kind of spread the word or increase access in rural areas to get patients who suffer from things like falls or other mechanisms of trauma to go to the hospital and get treatment? Great. One quick question before we break. Did you find that the reason, or do you have a reason why the severity was so much worse in the rural kids versus in the urban kids? Is it because of MVCs versus falls is the main reason for the difference? Yeah, it's a great question. That would be my best guess, but that's something I would definitely need more study with a more granular database, so unfortunately we didn't have things like injury severity score at our disposal, so being able to kind of see, you know, what is that distribution of where the injury, you know, kind of a clinical measure of injury severity would help us elucidate that. Great. Well, thank you to all of our presenters. These are really interesting topics, and if you have any further questions, you can join the authors in the conversation lounge. Thank you. Hi, everyone. Thank you for joining us again. We're now on the top abstract discussion, the spine subsection, and we have all our top authors here, and we're going to start with the protocol-driven early tracheal extubation in patients with flaccid neuromuscular scoliosis and preexisting lung conditions. This is from Jeffrey Bijan Hattif, so if you don't mind giving us a synopsis of the research, and we'll play some pre-recorded questions from our different physicians. Thank you. Thank you for having me. My project focused on neuromuscular scoliosis in children. At our institution, we implemented a protocol wherein children would be left intubated after surgery and brought to the ICU and then extubated directly onto BiPAP. So these are children with diagnoses of either muscular dystrophy or spinal muscular atrophy and flaccid neuromuscular scoliosis. Seventy-five percent had severe restrictive lung disease, and nocturnal BiPAP was required in 68 percent of them, and all patients either had a post-respiratory fusion or a growing rod implementation with the average number of instrumented levels being 17. Once they were brought to the ICU and extubated, the average ICU length of stay was 1.8 days. The average overall length of stay was 6.7 days, and our main focus was on the complications. The patients, there were a few complications. There was only one reintubation, one case of pneumonia, and three total complications. So we did find, comparing the patients with spinal muscular atrophy and muscular dystrophy, that the children with SMA were younger and the patients with muscular dystrophy were more likely to have higher blood loss and transfusions, but overall length of stay was similar. Our conclusion was that using a protocol-driven approach with multidisciplinary team, we're able to have immediate extubation after surgery with a very low number of complications and excellent clinical outcomes. Thank you. Thank you for those synopsis. We have a question from Dr. Schlatterhoff on this research. Hi. Thank you for your interesting presentation on your topic. Expedient and safe extubation after long-term deformity correction is a great area to invest in. So I have a couple of questions for you. One, why did you limit your study just to areas of deformity and scoliosis that could really use early extubations and studies like this? And have you looked into protocols and other individuals undergoing long segment corrections such as an AIS? What was your overall goal of the study? And what do you think the future directions are going to have with the study? I know that your end was relatively low. I'm not sure how long this data was collected over or if you think that you're going to be able to get more individuals into your study so you can have stronger powered conclusions or different conclusions with more individuals in the study. So I didn't hear the first part of the question. I think it was regarding the etiology of the scoliosis. We primarily focused on this due to the restrictive lung disease. The most common cause of neuromuscular scoliosis and the most common surgery that we would be doing in our institution would be for cerebral palsy. Those children don't typically have spastic condition. They don't have a flaccid condition. And they don't typically have the degree of respiratory insufficiency that these children do, these etiologies. That being said, we do the specific protocol focused, the research on the protocol focused on these patients with the flaccid neuromuscular scoliosis. But at our institution, we do drive for early extubation in all patients. Regarding those with AIS, that also is protocolized at our institution with the help of anesthesia pain. Those patients go to the floor primarily and are mobilized on postoperative day one with the hope of an early discharge, usually by postoperative day three to five. Thank you. Moving over to epidural analgesia reduces postoperative systemic opioid use following selective dorsal root rhizotomy in children. This is from Madeline Carsten. If you don't mind giving us a synopsis, and I have a question for you from the audience. Thanks. Yeah, absolutely. Thank you so much for having me. So in our study, we compared postoperative opioid use and other clinical measures between a cohort of pediatric patients who underwent selective dorsal rhizotomy. One group was managed, their postoperative pain was managed primarily with systemic opioids only. And the second cohort had an epidural catheter placed for typically around three days postoperatively. So we compared primarily postoperative opioid use systemically between the two groups, as well as respiratory support, length of stay. And we found that that placement of epidural catheter led to a significantly lower amount of postoperative opioids required in this group on postoperative days zero through four. We also found that patients who had the epidural catheter placed required less postoperative respiratory support on postoperative day one. And we also found that the reported pain scores between the two groups were equivalent. Although the epidural catheter group had a longer length of stay, we ultimately concluded that epidural analgesia can be seen and used as an additional pain management tool for patients undergoing selective dorsal rhizotomy in efforts to reduce the amount of systemic opioids that are used to manage pain in the pediatric population. DR. FRANK MARGOLIS Thank you. I have a question from Dr. Jarasek about your topic here. DR. FRANK MARGOLIS Hello, my name is Frank. I'm one of the neurosurgery residents at Penn State Hershey. It was with great pleasure that I read your abstract, listened to your abstract on the use of epidural analgesia and to see whether that would reduce systemic opioid use in a patient after selective dorsal rhizotomy. I think it's a very important clinical question. I mean, obviously, anything that we can do to get patients off of narcotic medications sooner is going to help in terms of their longer-term management, in terms of their potential risk of addiction, other things of that nature, and risk of complications like constipation and other side effects of these agents. I think it's a very interesting clinical question to ask, and I think it's good that you had a very select patient population in which you asked this question to start with. Maybe some of the heterogeneity among your patients, obviously, if you have such a narrow group to work with. Again, when you're making a conclusion at the end, obviously, helpful to think about the limitations about this potentially applying to other patient groups, giving the small group of a pretty small clinical population that you're working with here. You did a great job identifying your primary outcomes, looking at whether the use of these epidural analgesia reduces systemic opioid use, and then looking at the effects on the systemic opioid side effects. Obviously, it's hard to have a true randomized control trial in this setting. It's kind of working with what you have in terms of the surgeon preference about who got the epidural catheter versus who didn't, but I think you did a good job of acknowledging the limitations of that and sort of working with the data that you had available to analyze and draw the conclusions that you did. My initial questions was why you ended up dichotomizing your pain scores as opposed to working with just the straight NRS score. I got a little bit of clarity about this later on about the differences in the pain scales and pain scores that are used among different assessments of the pediatric population that you had in your study, so that question was answered for me. Again, a little bit difficult when trying to really get down to the granularity of the data, but understandable and an understandable challenge that you were working with. One of the differences you found that the use of epidural catheters increased the average length of stay. I was curious as to what factors you thought led to that increased length of stay. If you don't mind sharing your insight on this. Yeah, absolutely. So, thank you so much for that question. So, yeah, and sort of in relation to the first thing that you were wondering about, we had to dichotomize our pain scores into no or mild pain and then moderate to severe because unfortunately due to the retrospective nature of this study, there was not a uniform pain score that was used for all patients. There were three different pain scores that were used sort of arbitrarily among the patients and so we sort of were able to dichotomize all three of those pain scores into uniform categories which we used to assess the pain. So, I know that was answered for you. The reason, you know, we're not totally sure why the patients who had the epidural catheters had a longer length of stay. An important part to our study is that these two groups were actually operated on by different surgeons. So, it was really a second surgeon who came into our department who began using epidural catheters for this cohort of patients and we think that just he maybe managed them more conservatively and just they usually tended to stay a few extra days longer than the patients who were managed only with systemic opioids. We also didn't know if, you know, maybe having the catheter removed patients needed to be monitored for an extra day or so. So, we don't have like a super clear answer for that, but I think most likely we can attribute it to difference in surgical surgeon preferences since there were two different physicians managing each group. Thank you. That's so insightful and pretty cool idea. Thank you. Next, we're going to cross over to risk factors for proximal junctional kyphosis in pediatric deformity patients treated with halo-gravity traction and posterior spinal fusion. Amir Amanullah, if you don't mind sharing your synopsis. Hi, everyone. Thank you so much for having me. So, our study I was looking at, we had two primary objectives. So, we wanted to look at risk factors for proximal junctional kyphosis, which is a common complication in pediatric posterior spinal fusion, postoperative complication, in patients who specifically undergo preoperative halo-gravity traction, and we wanted to see if there was a relationship between the UIV, which is the upper instrumented vertebrae, being relatively caudal or cradle to the other vertebrae of interest. So, what we did was it was a retrospective study design, and we identified three vertebrae of interest. It was the UIV, which is the upper instrumented vertebrae. We also looked at the upper end vertebrae, which was the vertebrae that was the most angled from the horizontal, and then we also looked at the most level vertebrae, which is the level that was most parallel to the horizontal. So, all of our patients, they had six-month minimum follow-ups, and our patient cohort, we had 25 patients with 32% developing PJK, and we essentially, this is a follow-up study to a previous study we did at our institution, where we looked at risk factors for PJK in specifically a neuromuscular scoliosis cohort, and in that study, we found that halo-gravity traction was a risk factor. So, we wanted to delve a little bit deeper into that. So, in this study, we had a cohort that consisted of all three of AIS, congenital, and neuromuscular scoliosis, and the key conclusion we found in the study is that patients who develop PJK who underwent halo-gravity traction and then posterior spinal fusion, they had greater preoperative most level slope. They had an overcorrection of the sagittal balance. So, from what I understand, I think when you have sagittal imbalance, it's usually when patients have a greater than, I think, five centimeters of the sagittal vertical axis. All the patients, they were below the five centimeters. However, they had a significant decreases in both the C2 sagittal vertical axis and also the C7 sagittal vertical axis. Additionally, we also found that patients that develop PJK, they tended to have less cervical lordosis, which we define as more cervical kyphosis in the cervical spine, and we looked at the relationship between the UIV and also the MLV and the UEV, and we found there was no relationship whether the UIV was cranial or caudal to those two other vertebrae and development of PJK. And our study was novel because from what I understand, when we looked at the literature, no one's really looked at risk factors for PJK in a cohort that's undergone halo-gravity traction, and no one's really looked at whether or not there's a relationship between the UIV to other vertebrae of interest and development of PJK. And finally, we recommend that when we're monitoring pediatric patients, we look at the cervical spine and also sagittal balance parameters if perioperative halo-gravity traction is used. Thank you. Thank you so much. A question from Neil Patel here. Proximal junctional kyphosis after spinal deformity correction surgery is a great topic for investigation. Thank you for this excellent talk. I have a couple of questions for you. One, what was the patient selection criteria for application of halo-gravity traction in your study? Two, how do the cohort of pediatric patients undergoing halo-gravity traction prior to their deformity correction surgery compare with a cohort of patients who did not undergo halo-gravity traction prior to their deformity correction surgery? And three, how did the data you presented change the practice of applying halo-gravity traction prior to deformity correction at your institution? Thank you. So I'm trying to—I couldn't remember what the first question—I had a little bit trouble hearing it. But for the second question, so with our study in our cohort, we only had patients that were only—they only had halo-gravity traction. I think a follow-up study would be a great study where, one, we—ideally, we would love to balance between AIS, NMS, and also the congenital and have a cohort that underwent halo-gravity traction and patients who didn't go under halo-gravity traction. Number three, I think from our study, we haven't—we haven't put it into practice because this is the study we found that the overall cohort was small. So we want to ideally do a future study with an expanded cohort. But comparing this study to the previous study that followed or came before this, what we found is that when you had NMS, patients that had neuromuscular scoliosis, the halo-gravity traction was a predictive factor. But what we think is that we didn't find any differences between the actual classification of the scoliosis and diagnosis between AIS, NMS, and congenital. And one reason we think that is because, one, all these patients, because they went under halo-gravity traction, they had larger curves. So the curves were probably more homonymous, and they—you know, that had a factor in there. I think for the NMS cohort, the curves were smaller compared to some of the AIS and the congenital curves we had in the study. All right. Thank you. Next is diagnostic accuracy of an abbreviated STIR magnetic resonance image sequence in pediatric spine trauma. We have Christina Mieko-Soyama, if you don't mind sharing a small synopsis of your study. Sure. Thanks for having me. So our study, basically, I was interested in it because, obviously, there's a lot of pediatric spine traumas. The spine MRIs take a long time, and kids require sedation. And so I worked with our neuroradiologist and one of the medical students to create kind of an abbreviated sequence, and we figured that STIR was the best sequence to use since that's the one we primarily look at for injuries. And then we tested all these STIR sequences and basically then put it in all the MRIs that we're doing as part of our standard of care. And so over a year and a half, we looked at, I think, 26 different MRs, and it was including CT and L-spine. And we compared the quick STIRs to the standard STIRs, had two board-certified neuroradiologists compare them, and then I also compared them as well. To calculate sensitivity and specificity for detecting injuries. And interestingly, our specificities were pretty high for the quick STIR sequences compared to the regular STIRs. And then sensitivities were a little bit more variable when we ended up breaking it down by vertebral region. And we were looking at all different things such as like ligamentous injury, ligamentous disruption, vertebral fractures, spinal cord injury, and that kind of thing. And we looked at all those separately for each of the scans. And then we broke it down by vertebral levels. And so we found that at OTC2, which is, you know, the most vulnerable levels in children, we found that the sensitivity and specificity were both very, very high. So it's a great study for looking at those levels specifically. And then when we broke it down by kids with clinically significant injuries, and we identified those as, you know, kids that we either put in a TLSO brace or kept in a collar for longer. We unfortunately didn't have any surgeries over this time period. But we found that we also had a pretty high sensitivity and specificity for both those as well. And in comparison, the quick STIR was two minutes and 19 seconds compared to an average STIR, which is usually about four minutes. So if we can, you know, get these scans on kids who are, you know, traumas, head injuries and sick and can't be sedated, then, you know, two-minute laying flat scan is not so bad. And so our conclusion was, you know, this is a good kind of preliminary test, maybe. And obviously, a lot bigger studies need to be done to see if it's actually going to be clinically useful. Thank you so much for the effort of time because we don't have much time left. I'm going to move over to the next topic, Magnetic Resonance Guidance, Guided Laser Institutional Therapy for Palliative Rhizotomy, a Novel Technical Application by Vijay Misora Vindra. Hi, thanks for the opportunity to present. So this is a technical report of two cases treated at Texas Children's Hospital by the senior author on this, Dan Curry, who's an expert in laser guided ablation. And these were two patients with spastic quadriparosis who were treated with laser guided dorsal rhizotomy via percutaneous approach. Both patients were successfully treated and discharged from the hospital within 48 hours with improvement in their modified Ashworth scale scoring system, no re-treatment for spasticity needed to date. This is a novel technique that could be applied for patients needing rhizotomy, but we need to study this technique further and compare it to traditional techniques including intrathecal baclofen pump placement and traditional open, both selective and limited dorsal rhizotomy. I have a question from Dr. Giuffrani. Hi, my name is Ryan Giuffrani, I'm one of the Chief Residents at Penn State Hershey. First off, congrats to Dr. Ravindra, Dr. Currie, and Dr. Harris and all y'all's collaborators for this very interesting application of MR-guided lipid spasticity, it seems you guys have successfully demonstrated the feasibility and safety of this procedure in your two patients. I'm looking forward to reading the manuscript, I'd love to know much more about this procedure. Most of my questions fall in the realm of how and when and to whom I would do this procedure myself in my future career. Yeah, excellent question, so the indication for this, really a palliative rhizotomy, this is not selective, it's a pure dorsal rhizotomy, but not selective, and so indications are definitely to improve the ease of care, hopefully stabilize spinal deformity, provide pain relief for spasm-related pain, and in these two cases, a baclofen pump was discussed but not recommended for two reasons. In one case, the family just told us that they were not willing to commit to the long-term maintenance of an intrathecal baclofen pump, and in another, the insurance denial was the reason for not placing a pump. And with this in mind, we tailored this minimally invasive treatment to achieve the goals of surgery that I mentioned at the beginning, and avoid the access-related morbidity, post-operative pain, and potential for spinal fluid leak. Thank you so much, I think we have a question for Dr. Sayama, is it okay if I play a small question here from Dr. Lane? A few questions regarding this study, firstly, as you note, the N is fairly low, were there only 21 pediatric spine trauma patients during the period of the study, or were there some excluded prior to this step in data acquisition? Were there some patients who did not receive the quick-stir MRI sequence, and if so, why not? So if you don't mind sharing your insights on these questions. Yeah, definitely a pretty small number. I think we did exclude several patients just because the imaging either wasn't sufficient or some of them, since it was a fairly new thing that we started, the text just didn't do, even though we had, we have just an order box that clicks it and said, add on the clicks for study. And so there were probably some patients that were missed, but I would say maybe five patients that we excluded, and then maybe, you know, 10 or so that we missed just because it wasn't done, and so it didn't even get into our database. Very good. Well, thank you for this wonderful session, lots of good science coming out. And I want to remind everybody to return to the Remo Discussion Lounge and visit our Exhibitor Hall so we can keep our process going on here and keep everybody engaged and involved. Thank you so much. Well, welcome back to our abstract discussion on the technical advances. We have a wonderful panel today, and so I'm excited to introduce them to you. We'll start with Elsa Olson. She's a third-year medical student, and she'll be talking about design and testing of high-resistance ventricular catheters, an initial feasibility study. So the current CSF shunt system consists of a ventricular catheter with side circular holes as inlets and a valve that regulates flow, and continuous flow may be a cause of potential occlusion. So our idea was could a redesign control the CSF better, thereby preventing occlusion? So it was a feasibility study. We wanted to determine if novel designs could, in fact, regulate flow, and then secondarily we wanted to know if the new designs could actually help prevent occlusion. So we worked alongside the local university's mechanical engineering department, and with their assistance we used computational fluid dynamics and finite element analysis, and we theorized and produced a few catheter prototypes. We created an apparatus to test the flow through a ventricular system, and we found out that our modified U-shaped inlet prototype actually showed the most full rate control across various pressures. And so we did find that high-resistance catheters can be designed and made to mimic current catheter valve systems, and so we hope to complete further study to see the clinical impacts. This is always a topic of great interest. There have been so many shunt modification designs made since the 1950s when shunts were first introduced. In your abstract, you didn't mention specifically what pressure at which you were noting a difference in terms of the resistance for opening. Did you guys look at that, or is that something you're planning on looking at next? That's something we're planning on looking at next. We wanted definitely to run more trials, especially when we found the single prototype that seemed to have the most control. We did have some inconsistencies with prototyping, and so we were hoping to modify both our testing apparatus as well as how easily replicated it will be to test the modified U design. And so we're hoping to break it down a little further and see where that design has the best control. I know this is a feasibility study, but what are some of the next steps for the project in terms of testing either in an in vivo or more clinical scenario? So we definitely want to see how these various geometric shapes relate to rates of catheter occlusion. That's our biggest next step. So are these new shapes better or worse compared to the standard of care? Obviously it's something that's looked at often, and so that's probably the next question we want to answer before we test in vivo. Excellent. And is there a specific patient population that you think these catheters might be best suited for? What was kind of the conception behind choosing a high resistance catheter? So I think these are probably most easily employed in cases where we're concerned about over drainage. So for example, in patients with split ventricles syndrome or patients prone to developing subdural hygromas or hematomas. Excellent. Well, we're looking forward to the follow-up of that, and maybe it'll make a difference, we hope. Thank you. So we're going to move on to Catherine Kelly next. She's a medical student at Vanderbilt University, and her abstract is entitled The Pediatric Neurosurgical Care During the COVID-19 Pandemic, a Single Institutional Review. Hi, thank you all for having me. So I'm going to discuss briefly. As of November of 2020, the state of Tennessee had approximately 250,000 COVID cases, and the study of the delay of pediatric neurosurgical care due to COVID-19 had yet to be studied as of this summer. And so concerns had arisen regarding the dichotomization of elective and non-elective procedures and the potential risk to patients of delaying their care. So we conducted a retrospective study of all neurosurgical inpatient consultations at Vanderbilt, inpatient appointments, and neurosurgical operations between the period of March 23rd of 2019 through April 23rd of 2020, so about a calendar year. And the patients were delineated by the March 23rd, 2020 Tennessee gubernacular order to see selective procedures. We analyzed the differences in patient care between these two time periods. Overall, we found that there was an increase in distance and the median travel for neurosurgical care for pediatric patients, as well as an approximate 30% reduction in all cases, specifically in the areas of trauma, craniotomies, and functional procedures. Inpatient consultations decreased, and inpatient appointments also decreased. However, telehealth outpatient appointments significantly increased from zero to 10 a week. So overall, there's an unclear reasoning for the increase in median travel distance, and telehealth poses a viable option for low-risk, non-urgent appointments during pandemic times. It's possible that the decrease in trauma was due to an overall reduction in motor vehicle accidents during the pandemic times, and that a conversion to virtual clinics might represent rapid practice adaptations. Overall, we're going to need to study this question with more data now that we've had several more months, and continue to understand the long-term implications of the impacts of changes in pediatric neurosurgical care during pandemic times. So clearly a really timely topic, especially as we're all well within our second wave right now. Is there anything that you may have gleaned or learned from this first pass of kind of looking at the patient population that has served you now, dealing with patients during the second wave? Certainly it's understanding more of the importance of telehealth. I think that what we've noticed about it is a non-risky way for non-urgent patients to be seen in clinics still and stay on schedule, rather than delaying all of them and seeing their care. And it makes patient parents less concerned about contracting the virus as well. Something that will be important going forward, I think, is to figure out the reimbursement for this. We've received some pushback overall, outside of neurosurgery as well, but for many specialties about the lack of reimbursement for those virtual visits, and so that'll be something moving forward we'll have to consider. That's certainly interesting, and in your data that you presented, it looked like the number of private insurance patients that you were seeing went down, whereas the number of Medicare and Medicaid patients increased. I know Tennessee is one of those unique states that has all coverage for pediatric patients under TennCare and Medicare. Is there something you feel may have represented from that, or something that you were noting within your patient population that might have accounted for that shift in insurance? It's quite possible that children from families with a higher median income in private insurance were delaying their elective cases. All patients were asked to do that, but it's possible that families that are of a higher income status were more comfortable putting off procedures because they feel that they have access to care. And speaking with some patients who were covered by Medicare or other public insurance options, that they felt less comfortable. And I think that's also reflective in the increase in distance traveled for care. It's potential that these families, the health-seeking behaviors change because they felt less comfortable during a pandemic going to actual local centers and might have preferred to go to an institutional center like Vanderbilt. And is that something you're noting as well after kind of the initial first wave that went through Tennessee? Was there an increase in the type of acuity that you were seeing or any delay of care that might have been noted in your patient population? I think both across pediatrics and adult, we did note that the severity of patients presenting clinically was worse, especially in areas such as tumors. And this could possibly be because patients were concerned to come in for more minor symptoms for fear of contracting the virus and potentially were waiting longer. This was also seen with symptoms of shut infections, but children were having more days of time in between actually presenting to the emergency department. And so as the South is now getting a large second wave of record numbers, that'll be something important for us to continue to study the rest of this year. Well, certainly very timely. And again, thank you so much for your abstract. So next we'll move on to Nathan LeClaire. He is presenting his comparison of 2D head photography to caliper and optical scanning for assessing craniometrics. Hi, thank you for having me. So the abstract we're discussing here is actually an offshoot of a larger project, the Connecticut Children's Medical Center. So that's involving the development of image-based or image analysis software that will quantify craniometrics from top-down pictures of the patient's head. And so what we're doing here is seeing how the measurements from this new method match up to conventional measurements, basically from calipers or from 3D laser optical scans. And so what we find is that using a series of correlation coefficients and interclass correlations that basically measure how the agreement between these two different measurement modalities, we find very little agreement between our new photography-based analysis versus caliper measurements. We think that's probably likely to be the variability in using calipers and the measurements you get from that can be highly user and high user variability. But we find really good agreement with our 3D laser optical scans. So it's a promising result that may indicate that this accessible method of just taking a picture of the patient's head can have pretty accurate and objective measurements. And so we're taking this study and hopefully using it forward and trying to implement it clinically to follow up patients that, for example, like craniosynostosis patients, we can follow up their surgical outcomes more objectively. Awesome. Awesome. And just so we can better understand the technique, what's the feasibility or how easily would this be incorporated into someone's clinic? Yeah. Great question. So it really is just taking a picture of the patient's head. So anything like a cell phone camera can get a good enough resolution to take that picture. And you take that picture, you upload it into the software. What basically happens is there's an algorithm that will mask out the background from the outline of the patient's head. And from there, it will basically draw the angles and lines that will be used to then quantify craniometrics, most of the conventional ones, like cephalic index and cranial asymmetry, as well as novel craniometrics that our group is developing as well. And so you can think of it in terms of feasibility and implementing it, you can think of this as maybe something that can be used at each follow-up appointment after surgery. Wonderful. All right. Well, next, we'll move on to Dr. Schiff, who's going to be presenting his post-infectious hydrocephalus as an infectious disease epidemic. Oh, thanks very much. So hydrocephalus in the developing world is very often infectious-based. And we're learning that this can be a combination of both non-contagious and contagious infections. Recently, we found co-infections of both in the majority of the Ugandan children that we've been studying. And so this is a good case where building more technical hospitals and training more of all of you good people to go out there and do more surgeries isn't going to decrease the burden at all. So just as with COVID epidemic, you need to understand how the epidemic evolves. And yes, we do in some parts of the world have an epidemic of infections that create hydrocephalic cases. And we need to learn how to control them. So we've developed what I think is the first of the epidemic models that yields hydrocephalus after infants have been infected and recovered. We've tuned this to the local East African demographics that we're working with. And we actually can reproduce many of the numbers that we see in that part of the world. And really critically for the healthcare planners that we're going to have to work with to reduce our cases is we can do things like optimize how to do the planning for treatment versus prevention. At present, it's going to be all treatment. But as we learn more about these infections and we're able to prevent them, then we're able to actually change that balance substantially. And for ministries of health and for other agencies, that's absolutely critical to do. In this year, these findings are now out in three different papers, one in science translational medicine, one in emerging infectious diseases, and the other one in the physical review. Well, I was just intrigued by your modeling technique. And I was wondering if you could describe a little bit more what you were describing in terms of an epidemic versus endemic and how does that kind of relate to how we view cranial infections? So we actually think we're seeing both at the same time in these infants. An endemic is one that really doesn't depend on the cases yesterday. That's not at all the case with COVID and we all hope very much that COVID does not become endemic. It's well on its way to potentially doing that. But that's an epidemic where you have to contact uninfected and infected individuals or susceptible individuals. The endemic is something you expect from diseases as we found with these African babies or in rice paddies in Southeast Asia, you've seen this with mellioidosis, where it's seasonal and it depends on the infectivity of the ground, for instance, that you're walking through or encountering when it's moist enough to grow a lot of bacteria. And so we've got a fair amount of evidence for that now. We're gearing up the field work to learn about it in more detail, but the combination of epidemic and endemic disease is something that for better or worse, we've learned how to observe and track because of other diseases like measles and flu, et cetera, in the past, which often can appear to have both components. How important is contact tracing in these types of cases? In settings with high population density in rural African countries, I think it's absolutely impossible. And it's frightening just how contagious some of these viruses are. If you look at infants in this part of the world, they start off with a 3% congenital rate, for instance, of cytomegalovirus, CMV. So we all know about that, but unlike the U.S., by the time they're one year of age, it's over 95% that have contracted it. So contact tracing is useless in such settings. Well, really interesting abstract, and I enjoyed watching it, so I appreciate your commentary there. So last but not least, we'll move on to Jean-Paul Bryant. He is a medical student at the University of Miami, and he will be presenting on stereotactic EEG in pediatric epilepsy surgery and the five-year experience at Nicholas Children's Hospital. Thank you so much, Dr. Groves. So this was a five-year single-center experience at Nicholas Children's Hospital, where we were evaluating our cohort of 40 patients who underwent a SEEG procedure for invasive seizure monitoring. So when these patients originally presented to Nicholas, they would get a battery of tests as a method of what we call our phase one evaluation for their seizures. So this could include video EEG, fMRI, MRI, PET, SPECT, of course, just depending on each individual case. If after that, the case is not necessarily, quote-unquote, a slam dunk, or you don't know exactly what the next step is going to be, then they would advance to phase two evaluation after presentation at our epilepsy conference. The phase two would be the invasive type of evaluation, which could be subdural grid placement or strip placement, but we wanted to focus on our cohort that underwent SEEG. After that, they would subsequently get some sort of surgical procedure in most part, and then we kind of just recorded these outcomes and wanted to describe this group. And then in the distant future, since Nicholas has, like many centers across the country, acquired a ROSA robot, which can be used for depth electrode placement, we eventually want to compare the outcomes between those who were implanted manually and those who received robotic assistance. And so in your data, you had noted that, you know, about nearly half of the patients had had a prior surgery. In general, how many surgeries did the patients have prior to this particular procedure? Oh, that's a great and very important question. So 17 patients did have a prior surgery of some sort, and then an additional 10 patients actually had prior two-stage surgery. The surgery types varied. Some had lobectomies, corticectomies. Others had, you know, lip therapy, for example. So it varied, but yes, a good proportion of our cohort did have prior surgery, which we felt was important to describe because we were still able to implant the defilectroids safely and had a very, very low complication rate. And I didn't quite catch it in your abstract, but how many of the cases were done with the ROSA robot versus without? So these were all, none of these cases in the abstract involved the ROSA robot. So this is kind of our pre-robot scenario, if you will, which is going to, again, be compared later to those who did receive the ROSA robot. Now, we are still collecting data. So this is really an ongoing project with a live database. Well, wonderful. I'm not seeing any additional questions coming in. So I just want to thank the panelists again for such engaging conversations and to remind people watching that the abstracts are available for viewing as well. And if you'd like to continue the conversation, please enter Conversation Lounge at any point, and we hope that everyone has a great meeting. Hello, everyone. I'm Allison Alexander, and I'm going to be moderating this panel on trauma. We're going to have everyone quickly present a little bit about their poster, and then we can do questions one at a time. First, I'd like Dr. Newman, she's a resident at Emory, to talk to us about her poster, which was a comparison of the infant face scale to the pediatric Glasgow Coma Scale for predicting neurologic severity and outcome in children less than two years of age. Dr. Newman? Hi, everyone. My name is Sarah Newman, and we're so thankful to be here talking to you today. I'm here with Dr. Rindler, who's going to speak to you a little bit about our study. I'm Dr. Rimmer Rindler. I'm a PGY-7 who was also involved in this study. So as Dr. Alexander mentioned, we evaluated the infant coma scale or the infant face scale, or IFS, as a neuroassessment tool for children under the age of two years old. Most of us use a pediatric version of the Glasgow Coma Scale to evaluate the neurological status of young patients who come in after a traumatic brain injury or other neurological problem. But applying it to the youngest of children under the age of two years has some challenges, although despite the adaptation. So the infant face scale was developed as a modification to the pediatric Glasgow Coma Scale to include several additional variables and several additional clinical pieces that would be more applicable to the youngest children. This was assessed in this particular study as a comparison to the pediatric Glasgow Coma Scale. And we evaluated the performance of both on two specific outcome measures. One is how well they predicted the patient's current neurological status at the time of the traumatic brain injury. And we used a neuroimaging severity scale for any patient who had neuroimaging for evaluation. We also use the therapy intensity scale, which is a validated measure of the intensity of therapy that the child is undergoing, especially in the intensive care unit, mostly for intracranial pressure problems. The other outcomes that we were interested in evaluating was the patient's functional outcome at the time of discharge, which was evaluated by the Glasgow Outcome Scale Extended Pediatrics, specific to traumatic brain injury, and the Vineland Assessment Scale, which was a telephone interview with the children's parents at about one to two months after discharge from the hospital. We compared the performance of both scales for each of those four variables and compared different subsets of this population. We found that both the infant phase scale and the pediatric Glasgow Coma Scale performed fairly well in terms of predicting injury severity and also the outcome. The infant phase scale did perform a little bit better in predicting the longer term outcome as assessed by the Vineland Scale for the whole subset of the population. And it also, for the sickest children, for the children who presented with scales with neuroassessment scores less than eight, it had a better prediction of the therapy intensity that they ultimately underwent than the pediatric Glasgow Coma Scale. And so in conclusion, we do think that both the infant phase scale and the pediatric Glasgow Coma Scale are valid neuroassessment tools for young children, even under the age of two, despite the shortcomings for the pediatric Glasgow Coma Scale. However, the infant phase scale may be a better tool in general for identifying therapy intensity and outcome measures for a subset of the population. So this may be a better catch-all for applying it to children. Great, thanks for the summary. I did have a couple of questions. One is, this was an excellent study, but there were 156 patients. If you, how many, have you thought about trying to repeat this with a multicenters trial and how many patients and centers do you think you would need to enroll in order to get this to be more widely adopted and sort of validated by, you know, trauma centers nationwide? This is a great question. This was actually a multicenter study. We recruited children from the Massachusetts General Hospital for Children. That's where this project started. And then when I started residency here in Atlanta, we started this at a Children's Healthcare of Atlanta. Of course, like all prospective studies that are trying new tools and attempting to implement new assessment scales like this one, there requires a lot of buy-in to happen for it to be successful. And so this project was multicenter because of that fact. We needed more numbers to see whether there was a true difference or not. And also took a lot of time and buy-in to be able to do it. So we did reach the end that we had wanted to look at. 150 children was the number needed to include, to identify a difference of at least 10% between the two scales. So we were satisfied with that. I think the thing that would be most helpful is to include patients with more severe injury. Patients who had a glaucoma scale or an intubated scale less than 12 or so, because that's the patient that we really want to identify and treat aggressively and know what their outcome is gonna be sooner rather than later. Our cohort did include, did have about 10% of our children had more severe injuries. And that is representative of what we see in the population out there on a day-to-day basis. But still, it's likely that the differences are subtle enough that it may not be picked up on a population level study like this. Well, thank you so much for that great work. We're gonna, just for time reasons, we're gonna go ahead and move on. The next presenter will be Dr. Rebecca Reynolds. She's a resident of Vanderbilt. And she's gonna be speaking about protocolized management of isolated linear skull fractures at a level one pediatrics trauma center. Thank you for the opportunity. So isolated linear skull fractures are a common presenting symptom that neurosurgeons are consulted for throughout the country. And then many studies have shown that the management varies widely as far as admission, discharge, and duration of admission. And so our center started to standardize the management based on prior studies that we had done here as far as predictors of ER bounce back and issues with nausea and vomiting moving forward for these kids, which ends up being a primary predictor of reason for admission here. And so the full protocol is in my presentation, but essentially we decided to try to assess the safety and efficacy over the course of a year of the study and compare pre and post protocol patients retrospectively. The safety was assessed by 72 hour ED revisits and the efficacy was assessed by whether there was a decrease in admissions at our hospital. And the results showed that we successfully decreased the admissions from 52% pre protocol to 38% post protocol at our hospital of children who present with this diagnosis. And we saw a trend in the decrease of ED revisits, although this wasn't statistically significant from a 4% bounce back rate to a 1% bounce back rate. So this is a study that's still ongoing. I think one of the interesting pieces too, as far as the secondary outcome included in the standardization of this was whether neurosurgery needed to be involved in the care of every patient because we are a big trauma center for Tennessee and we have 150 mile catchment area. So we get a lot of kids who are transferred really far as I know many people who are on this call also work at major centers like this. And so I think questions moving forward for this study are whether children need to be transferred for this diagnosis, because they're often transferred purely for neurosurgical management moving forward. Yeah, I think this is a really important study. We also have a large catchment area in Colorado and patients are sometimes flown by fixed wing down from Wyoming for a linear skull fracture, which just seems like a not great use of resources. So I think, you know, continuing to publish on this is really critical. I had two quick questions. One is that at our institution, any kiddo less than two who has a skull fracture, we see them and follow up just to rule out growing skull fractures. Obviously the ones we catch, there are a few in the far between but that's sort of our protocol. I was wondering if you have any sort of part of the protocol. I didn't see that on your presentation or if that's not something you're as concerned about. It's a good question. We actually didn't include age as part of our criteria. We used three things. We used like the time since injury, the time window of observation, essentially the fracture location within this cranial vault. And then whether there was Zofran use or not, since that's what our prior research has shown as far as the biggest predictor of ER bounce back. But as far as the growing skull fractures go, since there's so few and far between, we actually have relied on the pediatricians to refer them back to us if there's anything that happens. And I have yet to see one in the six years that I've been here. And so it is something. I've seen a couple. They didn't happen. It does happen. All right. Well, excellent study. We are gonna have to move on again. Next we have Jordan Roser who's a medical student at Ohio State. He will be speaking about his poster, which has studied long-term functional outcome following surgical intervention for pediatric abusive head trauma. Take it away. Hi everyone. Thank you for having me. I'm excited about this opportunity to talk to you all. And I am, like she said, I'm a second year medical student at Ohio State University College of Medicine. And I've had the wonderful opportunity of working with Dr. Eric Srebnik at Nationwide Children's Hospital to look at the long-term functional outcome of pediatric patients that were suspected of abusive head trauma and ultimately received a craniotomy or craniectomy. So our patient population was a single center retrospective review of Nationwide Children's Hospital patients from 2007 to 2019. Our inclusion criteria was patients less than three years old, those that were suspected of abusive head trauma and ultimately received a craniotomy or craniotomy. We evaluated long-term functional outcomes using the pediatric cerebral performance category score. And by doing this, we had 36 patients meet our inclusion criteria with 27 surviving to discharge and one year of follow-up. Really the big takeaway from this is that we had 57% of patients on the PCPC scale have only mild to no disability with long-term functional outcome at the most recent PCPC evaluation. And we're optimistic that this could potentially lead to the idea that we could lower the threshold for, sorry, lower the threshold to have patients receive craniotomy or craniotomy for decompression based on pediatric head trauma. All right, great. I had one question, which was, did you look to see which types of injuries led to and indications led to patients needing surgery for abusive head trauma? Yeah, and really in our study, a lot of the indications were in congruence with prior research. We found that there was statistical correlation between retinal hemorrhage, cerebral edema, cerebral ischemia and coagulopathy on initial assessment that did correlate at a statistical level. All right, thanks so much. We will continue marching on. The next person we have is Dr. Joseph Pyatt, who's a neurosurgeon at Nemours Hospital. So please share your work with us. Thank you, thanks for the opportunity. I've been curious for a long time why black children die at higher rates after severe traumatic brain injury than white children. And the short answer is that they are injured more severely. That maybe that's not a big surprise, but there are other sort of lingering questions in the background about whether black children get the same care as white children and whether they have background medical issues that may make them more susceptible. The hook in my abstract title is Osaka-Blinder decomposition. What that is is a statistical technique for sorting out what's important among the covariates in a predictive model of mortality. So it begins with a logistic regression model of mortality. The entry criteria for this study was AIS score four, five or six, and the mortality rates were between 15 and 22%. And so it was a pretty sick group of children. The covariates that retain significance in the model are grouped in areas of interest. In this case, I looked at severity, mechanism of injury, demographics, insurance, and access or process. And the model works by pretending that the disadvantaged group has the same covariates as the advantage group, the same values for the covariates as the advantage group. And sorting out what difference this pretend counterfactual analysis makes for each of the groups of covariates. And the answer was that 95% of the mortality difference between black and white children can be accounted for by more severe injuries among black children. Yeah, excellent. I think this work is so important in looking at, how we can decrease the socioeconomic disparities that are so prevalent in our society. I am unfortunately not that familiar with the head AIS score. Can you, is there any subjectivity in that that might confound this? It's determined retroactively at the end of an admission. Okay. It's one of the factors that enters into the ISS, which is familiar to people doing trauma research. Right. Six is not survivable. Five is pretty bad. And there's a long list of pathological conditions that qualify as a five and similarly for a four. So with that entry criterion, we got a fairly sick group of patients. It was arbitrary. I needed a sample that had a high enough mortality rate to analyze and four, five and six was adequate to do that. Yes, excellent. And then why, I was just wondering why you were looking at black versus white rather than including additional ethnic or racial groups? Because the differences are biggest between black and white. Hispanic, non-black Hispanic children fall in between and Asian and other categories fall in between. So I just looked at the most extreme. Fair enough. All right. Thank you so much. And for our final poster, we have Theo Hanna, who's a medical student at Mount Sinai. And he looked at sex differences in the incident severity and recovery of concussion in adolescent student athletes from 2009 to 2019. Hi everyone. I'm a third year med student at Mount Sinai. I work with Dr. Lovell, co-founder of the Impact Neurocognitive Assessment and using a database of about 25,000 impact tests. We were able to design a severity index for concussion that correlates pretty well with recovery. And so we took that metric and we use it to evaluate gender differences in severity and recovery of concussion of young student athletes, which has not been well described previously. So for our paper, we use definition of a concussion as two out of five impact scores significantly deviated from baseline. And then recovery was a return to one out of five or zero to five significant deviations from baseline in the five impact competency scores. Then using a multivariable analysis, we found that females are more likely to be concussed than males and that's been demonstrated previously. But we also found that women suffered higher severity concussions driven primarily by differences in processing speed and symptom scores. And they also have longer recovery time on the univariate analysis. The incidence and severity results were robust in multivariate analysis, but when we controlled for initial concussion severity, we found that there was no gender effect on recovery time suggesting that males and females are recovering from concussion at similar rates, but females are just recovering from more severe concussions on average. We think this might help explain divergent results in the current literature about gender differences in concussion recovery. And we think that in the future, finding ways to address differences in symptom and processing speed scores might help reduce concussion severity differences in between males and females. Excellent. I have so many questions, but I'll keep it to one. Why do you think girls have a higher incidence of concussion? Do you think there are some prior studies showing that in soccer, girls have a higher incidence of concussion and it's thought to be due to decreased neck muscle strength leading to increased whiplash. Do you have any theories? I don't have any great theories. I've read about the neck strength and then also some neural mechanism differences as well. I don't think there's anything strong enough that I would throw a theory out. I don't really have a great idea of what the underlying cause is. And then one other question, you were speaking about football a lot in your poster. Were these children only playing football or was it all student athletes? It was all sports. We were talking about football because there is a slight increase in female participation and football has the highest frequency of concussion. So females being a gender with higher incidence of concussion plus playing this increased representation in the sport with high frequency, we think could become clinically relevant in the future. All right, well we have I think one minute left so I think we did a good job trying to stay on time. All of these were fantastic projects. Thank you so much for sharing them. For anyone else who's here and who didn't get a chance to look at the videos, they are available on the website and if you want any further discussion you can hop on over to the discussion room and again if you go to the main Dell NSP section website you'll be able to to find that there. Thanks again and we look forward to seeing all the papers that will come out of these excellent posters. Hello everyone and thank you for joining us. This will be our final poster session of the day and just to recap we aren't playing the videos during this session but those are available from your main screen. This will be a discussion about the top author posters for this session. We're going to ask each author to give about a one minute synopsis and then we have a couple questions. So I'll start with Alex Chung. Please share. Hi everyone, thank you for giving me this opportunity. So my project is looking at whether or not we can identify craniofacial abnormalities, specifically craniosynostosis that requires surgery just by looking at photos provided by the caregiver. So what we did was we first asked parents that were already referred to our neurosurgery clinic to provide us photos and I would then share these photos with the staff that are participating or the raters and these raters would then tell me whether or not they think there's craniosynostosis present or the absence of something surgically. And so what we found was all of the raters were actually able to accurately identify craniosynostosis that required surgery and there was actually a lot of agreement or substantial agreement amongst all the raters and we were able to find that not only was everyone very specific, there was also a high amount of specificity and accuracy when it comes to identifying these diagnoses. Excellent. I particularly enjoyed this because it's always frustrating to have someone travel a very long distance and then, you know, be recognized in the first five seconds that they don't have anything surgical. I have the pleasure of sharing questions from Dr. Rutge with all of you. So his first question to you is how did you instruct the parents to take the standardized photographs? Great question. So during my correspondence with the family, I would email them instructions along with examples of how we would like the photos and so these photo examples specifically show the baby head from the front, the sides, the top, and the back. So it's just five standardized photographs and they would try their best to recreate it as much as possible and of course not every parent can accurately do so just because babies can be quite fussy from time to time. So we've had some troubles but for the most part almost every family was able to follow. And did you find there was an optimum age or did you just have them send them in whenever the referral was placed? Whenever the referral was placed. All right, excellent. Well we may swing back around if we have more time but otherwise we're going to move on to Coleman at this point and I look forward to hearing about brainstem cavernous malformations. Hi, thank you so much for this opportunity. In this study we retrospectively reviewed the indications for operative intervention versus observation in pediatric patients with brainstem cavernous malformations. The goal is to describe the natural histories of both cohorts as well as to report institutional decision-making for plan of care. The primary outcome of interest was hemorrhage rate per patient year. Patients with deep-seated lesions who presented with without hemorrhage or obvious symptoms were not considered surgical candidates. Overall these patients experienced hemorrhages at a low rate comparable to that of operative cases with gross total resection. We believe that these findings suggest that with careful selection many of these patients may experience a relatively benign clinical course with observation alone and maybe spare the additional version of surgery. Is there a particular follow-up protocol for the non-operative patients like imaging once a year or six months or two years? So one of the limitations of the study was that a decent amount of patients were lost to follow-up so ideally there would be a standardized follow-up but because of the time because of how old some of these cases are there there was not any sort of standardized follow-up but that's certainly something that would be helpful for future studies. And then here's the tough one if you believe you've achieved a gross total resection why is there still a re-bleed rate? Yes that's a great question. So the naming of gross total versus subtotal resection was based on the operative report at the closure of surgery and immediate post-operative imaging. So there are going to be a couple of patients who slipped through the cracks but this was based on retrospective data so there's some imperfections there. I think in general it can be hard to interpret post-operative MRI scans from cavernous malformations right so determining that gross total is always a challenge. Well thank you for that synopsis. Next we will move on to our hemispherectomy paper, Wen Xia. Hey everyone, thank you for this opportunity. So our study aimed to evaluate the clinical characteristics and outcome of chemotherapy. We reviewed the medical charts of 60 patients with epilepsy between 2004 and 2019 who underwent hemispherotomy surgery at Children's of Alabama. All patients are younger than 18 years of age and we collected demographic information, pre-surgical and post-surgical variables and the data was summarised with described specific like meaning includes median mean for continuous variables and character variables were pressed as frequency and percentage and we also pre-operate vectors evaluate could be associated with seizure outcomes and use logical rejection analysis to identify which of these variables were associated with seizure freedom and we also the result is that there is association between seizure freedom and seizure onset age of first hemispherotomy surgery and term between the first seizure onset and the hemispherotomy surgery and the the we also suggest that the early hemispherotomy will get a better outcome. So one of the questions Dr. Rutge had was do you feel that there was a delay in doing the hemispherectomy and is that perhaps because this is this is a retrospective study and that moving forward there will be less delay or how would you address that? Yes, I think this is good. Okay and then what is the approach to patients who still have seizures after hemispherectomy? That's the hardest question. Yes, that is hard question because actually we have more patients who still need the hemispherotomy surgery. It can be a tough problem to manage that is for sure. Do you know if there were any deaths from SUDEP or related to seizures during the time of the study? No. Okay, thank you very much. Next, we will move on to hear about a model for interventricular hemorrhage from Dr. Grace Lai. Hi, thanks for this opportunity to share our research. So this is a little bit of a a change from patients. We're actually going to be talking about a pig model, a piglet model for post-hemorrhagic hydrocephalus of prematurity. The reason we wanted to create this model is because so I worked at Dr. James Drake's lab at SickKids and one of the things that he's investigating is using high intensity focus ultrasound to break down the blood clots. So you can actually treat, theoretically treat the blood clots like through the fontanelle using an ultrasound system. It's MR guided so you can you can like guide where you want the focus to be. So in order to prove that this works in preventing hydrocephalus, we had to make a model to create hydrocephalus with blood clots. So we injected blood directly into the ventricles of the pigs after we made a craniotomy and initially we just based it on previous research of what people have done in terms of like volume of blood and rate of injection. But we realized that a lot of people have used a blood that has been treated either citrinated or heparinized so it doesn't really clot. So we had to do it, we basically will take the blood directly from the femoral artery and inject it into the brain. And in the beginning, we were realizing that, you know, not all the pigs with the smaller amounts of blood that we were injecting, not all the pigs were developing hydrocephalus, which makes sense. I mean, even we see in our population, even the kids with a grade three, grade four, not all of them will develop, you know, shunt dependence. So we were interested in seeing like what are the variables that predicted ventriculomegaly that was prolonged. So these pigs were survived for 28 days. We looked at the amount of blood that was injected. We looked at the amount of clot that was formed based on a post-operative MRI. And then we looked at the amount of initial ventriculomegaly. So immediately after the surgery, and then every seven days we would do another MRI up to 28 days. And we found that surprisingly, it wasn't the amount of blood that was given to the pig, but it was the amount of clot that formed. And then more significantly, the amount of ventriculomegaly that the pig initially had that predicted the maximum amount of ventricular dilation, as well as the terminal ventricular volume. So I thought this was interesting. You know, it really is the blood clot itself that's forming, you know, because we don't really think about like, you know, how can we make someone get hydrocephalus? So, yeah, so we found out that and perhaps it has to do with like the CSF flow dynamics as well because of the initial ventriculomegaly. Do you know if there has been effort in the past to actually insert clot as opposed to liquid blood and then waiting for it to clot? Yeah, we did see one study in dogs where they injected like pre-formed blood clots. And they also found that it was, you know, the more clot they injected, the higher the risk of developing hydrocephalus for the dogs. Yeah. And then do you know how is it that the MR-guided ultrasound is expected to just lyse the clot without causing damage to surrounding tissue? Right. And that's something we're working on right now, actually actively. So there is a risk of effects to other tissue depending on, because our pigs are very small, actually much smaller than humans, but there is that risk. So we have to like work on the exact parameters, the settings that we put the ultrasound on to prevent that, as well as a more, I guess, sensitive measuring technology to measure the amount of, actually the ultrasound causes movement, microscopic movement. So that's something that the lab is actively working on as well. I suspect we will see a lot about that in the coming years, certainly promising technology. Yeah. Yeah. And the fact that the blood clot, I think, predicted the hydrocephalus, not the blood itself, you know, suggests that maybe breaking it down might help. Indeed. Agreed. Well, thank you for your contribution. Next, we will move on to hear about subdural empyemas from LaQuaida Boswell. So we did a retrospective chart review for patients that were seen at Children's of Alabama for subdural empyemas. To find those patients, we did a keyword search, and after that keyword search, we located 40 patients. 14 of those patients did not meet the criteria. They did not have a subdural empyema, so they were excluded. That left us with 26 patients. From those 26 patients, we gathered multiple variables that gave us information about demographics, clinical manifestations, outcomes, radiological findings, and surgical findings. I'm sorry, I lost my train of thought. So we collected all those variables, found all that information, and from that we found that we had, sorry, from that we found that about out of the entire cohort, about 20, about 50% of those patients had meningitis. About 65% of those patients had sinusitis, and then once we broke those patients up into seven years of age and older and six years of age and younger, we found that the six years of age and younger patients, about 75% of those had meningitis, and that for the seven years of age and older, about 94% of those had sinusitis. We also found that the rate that using MRIs was the most, was the best diagnostic way of finding the SDEs, and we also found that, sorry, yeah, then we found that MRIs were the most sensitive, CTs were less sensitive, and then we found that for the ones who had imaging study done seven days prior to the diagnostic scan, about 12 patients had imaging study done, and that imaging study was a CT. So one of Dr. Rutka's questions actually is directly related to those 12 patients. So do you think that if the prior imaging study had been an MRI, that that might have been diagnostic earlier? I do. A lot of those patients, and some of those patients, they probably would have found it with the MRI, and some of those patients, I think that other factors were involved in not being able to see it in the CT, but I do think a lot of those patients would have been found if they used MRI first. All righty, and then is there a way to minimize requirements for a second cranial procedure? Did you come across any specifics from patient to patient that made you suspect that they would need a second procedure ahead of time, or was that just as their course unrolled? No, ma'am, we didn't find anything that would suggest that they would need something, need a second surgery. Like you said, it was just something that happened once they progressed after surgery. All righty, well thanks also to you for your contribution, and finally we will move on. I believe we have a tag team here to hear about research productivity of neurosurgeons in Canada. We have Frederick Zhang and Farhan Mahmood. Hi, so happy to talk a little bit about our work. So we did a bibliometrics project on the predictors of research productivity among pediatric neurosurgeons in Canada, specifically with respect to aspects of sort of their undergraduate and postgraduate training, like whether their school was in Canada, whether they had a graduate degree, a PhD, or a master's degree, in addition to stuff like pediatric or otherwise fellowships. So we aggregated a data set of about 2,800 unique publications for the 39 pediatric neurosurgeons licensed to practice in Canada as of August. So we queried PevMed as well as World of Science to try to gather as close to comprehensive a data set as possible. Some of these papers can go back quite a ways, and classify them manually based on basic translational versus clinical papers, as well as sort of the quality of clinical research from a previous JNS pediatrics classification system. And then we fitted progression models to look at sort of the independent effects of these predictors, sort of adjusting for length of time since medical school. It's almost like a rate of publications in that respect. So PhD degrees were broadly predictive of increased productivity, roughly three to four times as many total publications, though the confidence interval on that is quite wide. Master's degrees, however, did not approach significance for total publications, basic science, high quality clinical papers, or first authorships. And then for basic science papers, we found almost non-pediatric fellowships are actually stronger predictors of productivity, namely because maybe there's some outliers in our data set that are strong publishers without having a pediatric fellowship. And so I think this is a really interesting data set for funding bodies and administration to determine sort of funding and training initiatives in a Canadian context. And I'd be happy to take any questions. Thank you. So Dr. Rucka's question is similar to one I had, which is, would you advise neurosurgery residents to obtain a PhD? Is this sort of like a chicken and egg? Like, do you get a PhD because you like to write or do you write because you're getting a PhD? Right, so that's actually an effect that's sort of difficult to tease apart, whether people who do take a PhD are more intrinsically motivated to do research. I can comment on recent surveys of neurosurgical residents in Canada stating that more than half are planning on doing sort of an enfolded degree in the residency and are interested in full-time academic practice. And that goes hand in hand with academic centres more increasingly hiring people with graduate degrees as part of their training. So I guess that is a broad trend that's sort of moving in that direction. All right. Well, thank you all so much for presenting. It gives me great personal pleasure to say we are done with this session. Though, everyone, please stick around because I think there's a video about next year's meeting that is coming up. And then as always, there is the conversation lounge, and then meet the leadership immediately to follow. So have a fantastic day. Hi, this is Dr. Douglas Brockmeyer, and I'd like to invite you to the 50th Annual Meeting of the AANS-CNS Joint Section on Pediatric Neurological Surgery to be held December 7th through 10th, 2021 in Salt Lake City, Utah. On behalf of my partners, Dr. John Kessel, Dr. Rob Bolo, and Dr. Sam Cheshire, we invite you to join us. We are looking forward to the opportunity to host you while providing the highest level of scientific and educational content. Our host hotel is the Grand America, a wonderful facility centrally located in the downtown area and near all of Salt Lake City's wonderful restaurants and world-famous attractions. The Grand America is truly a five-star luxury hotel. We have guaranteed run-of-the-house with ample meeting and exhibition space. While you're here, we hope you enjoy the hotel's dining facilities and wonderful amenities. Once you arrive, absorb yourself in the latest scientific content in the field of pediatric neurosurgery. Learn more about cutting-edge technical advances from our vendor partners, and of course, mingle and network with your friends and associates. And last but not least, soak in Utah's legendary hospitality. So, save the date, December 7th through 10th, 2021, to attend the 50th Annual Meeting of the AANS-CNS Joint Section on Pediatric Neurological Surgery. We hope you come to learn, but stay to play and recreate.

COVID-19 pandemic

pediatric neurosurgical care

retrospective analysis

surgical cases

clinic visits

urgent and emergent cases

elective cases

safety measures

preoperative screening

telemedicine

simulation-based pediatric fronto-orbital advancement course

realistic simulation models

translocator artery Onyx embolization

intraosseous vascular malformations

operative time