4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0116
Fo r a m e n m a g n u m s t e n o s i s i n a c h o n d r o p l a s i a - w h o r e a l l y n e e d s
decompression?
Ryo ANDO1
1

Pediatric Neurosurgery, Chiba Children’s Hospital, Chiba, Japan

Introduction : Foramen magnum stenosis in achondroplasia can cause severe neurologicalcompromise especially in earlier stage of life. However, which patients really need surgicalintervention is still unclear.
Material & Methods : We retrospectively reviewed our experience of sixteen achondroplasitc
children regarding the size of foramen magnum, especially focusing on anterior-posterior diameter,cross sectional area, and the characteristics of its shape. The patients were divided into two groups
based on whether the surgery was indicated. These radiological data was compared and analyzed.
Cervicomedurally signal change or deformity with neurocopmression were regarded as surgicalindication.
Results : Surgery was performed for eleven patients (69%). Median age when surgery was
performed was nineteen months. Average anterior-posterior diameter was 5.2mm on surgery
indicated group, whereas 10.7mm on surgery non-indicated group. Average cross-sectional
area were 50mm2 and 84mm2, respectively. Premature synostosis on posterior intra-occipitalsynchondrosis was observed on all surgery-indicated group, which resulted in the insufficient
expansion of posterior edge of foramen magnum to posterior direction. One patient developed
syringomyelia which required decompression at 8 years of age. The other one who also developed
tonsillar herniation are now conservatively followed.
Conclusions : Premature fusion of occipital synchondrosis was associated with severe foramen
magnum stenosis and neurocompression. This also affects the undergrowth of posterior fossa throughthe whole developmental stage. Continuous attention should be paid to the possible cerebrospinal
circulation disturbance on craniovertebral junction even in the later age of children.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0153Long-term prognosis in patients associated with scoliosis and Chiarimalformation type I
Yasuhiko HAYASHI1, Masahiro OISHI2, Sho TAKATA1, Ryoken KIMURA1, Mitsutoshi NAKADA2,
Hideaki IIZUKA1
1

Neurosurgery, Kanazawa Medical University, Kahoku, Japan,
Neurosurgery, Kanazawa University, Kanazawa, Japan

2

Introduction : Chiari malformation type I (CM-I) often associated with syringomyelia and scoliosis.
The objective of this study was to determine the long-term functional prognosis of patients withscoliosis and CM-I at our institute.
Material & Methods : We retrospectively identified 28 patients 18 years of age or younger who weretreated for CM-I. Among these patients, 14 (5 male and 9 female) between the ages of 5 to 18 years
were diagnosed with scoliosis. The study patients were evaluated in terms of age, sex, degree of
cerebellar tonsil descent, location and width of syrinx, clinical symptoms, duration of follow-up, Cobb
angle, scoliosis progression, internal and external fixation for scoliosis, social status, and after-school
activities.
Results : Twelve of the 14 CM-I patients with scoliosis had syringomyelia. Their preoperative tonsillar
descent ranged from 3.1-24.9 mm (mean: 13.7 mm), and all of them experienced improvement in therange of -1.5-5.7 mm (mean: 2.6 mm) postoperatively. Ten of the 12 CM-I patients showed a reduction
or disappearance of the syrinx postoperatively. Symptoms due to CM-I were present in four patientsand resolved postoperatively in all. The patients’ Cobb angles ranged from 24 to 65°(mean: 36.2°)
preoperatively, and 15 to 79° (mean: 33.7°) postoperatively. Eight patients received conservative
therapy for scoliosis and the other two patients underwent internal fixation of the spine.
Conclusions : FMD provided benefits for the majority of CM-I patients with scoliosis. The
patient’ scoliosis did not progress, allowing for the avoidance of internal fixation and for the
maintenance of social status and after school activities.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0165
Posterior Intra-Articular Distraction Technique to Treat Pediatric Atlantoaxial
Instability
Mading ZHOU1, Wanru DUAN1, Zan CHEN1
1

Neurosurgery Dept, Xuanwu Hospital, Capital Medical University, Beijing, China

Introduction : The surgical treatment of atlantoaxial instability in pediatric patient is chalenging
as the presence of congenital malformations with possible abnormal vertebral artery. Historically, thefirst choice of surgical treatments is anterior transoral decompression. However, the anterior transoral
decompression might be really limited in pediatric patients due to risks of wound infection, CSF leaks,
difficulty swallowing and etc..
Material & Methods : This is a retrospective descriptive study which included 15 patients ofatlantoaxial instability whose age was less than 18 years at the time of clinical presentation. All had
one or more radiologic markers of congenital atlantoaxial instability. All patients underwent anterior
soft tissue released through a posterior-only approach, followed by intra-facet cages implantation,cantilever correction, and instrumentation. Clinical results were measured using the Japanese
Orthopedic Association (JOA) scale, and radiographic measurements including the atlantodental
interval(ADI), posterior atlantodental interval(PADI), the distance of odontoid tip above Chamberlain’sline, clivuscanal angle (CCA), and triangular area(TA) of cranio-vertebral junction.
Results : The follow-up time ranges from 18 to 72 months with an average of 41.4 months. JOA
score increased from 12.50 to 14.56. The mean TA decreased from 253.73 mm2 to 185.36
mm2 postoperatively. The mean CCA improved from 135° to 145° postoperatively. There were noevidence of complications or iatrogenic secondary cervical deformity during follow-up. Radiologicalevaluation showed satisfactory corrections and bony fusions of C1/2 facet joint in all cases.
Conclusions : Posterior intra-articular distraction followed by cage implantation and cantilevercorrection can be one of the safe and effective way to solve this challenging pediatric spinal disorder.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0029The Fourth Ventricular Roof Angle in Chiari-1 malformation - The Queensland
experience
Jed ROBUSTO1, Robert CAMPBELL1
1

Neurosurgery, Queensland Children’s Hospital, Brisbane, Australia

Introduction : Pre-operative fourth ventricle roof angle (FVRA) has recently been highlighted as anovel radiographic predictor of clinical severity in Chiari-I malformation (CM-I) (Seaman et al., 2021).
This has led to suggestions that FVRA could be included in algorithms to determine indications forsurgery. We aimed to test the accuracy of FVRA as a predictor of clinical severity and its effect on
post-operative outcome in a cohort of paediatric patients who underwent decompression for CM-I.
Material & Methods : Patients undergoing surgery for CM-I at the Queensland Children’s Hospital(2006-2018) were included. Data was collected from 66 patients aged 0-18 years. Post operative
outcome was assessed by calculating Chicago Chiari Outcomes Score (CCOS) at follow up. The
FVRA was taken from a mid-sagittal MRI as previously described (Seaman et al).
Results : Whilst results from Seaman et al. demonstrated a strong correlation between a FVRA >65°
and symptomatic CM-I, this did not translate to our dataset (p=0.61). Pre-operative FVRA is not usefulas a predictive tool for post-surgical outcome as assessed by CCOS (p=0.50), and post-operative
reduction in FVRA did not correlate with improved outcomes (p=0.81). We note significantly worse
outcomes in patients presenting with pre-operative brainstem dysfunction (p=0.03).
Conclusions : Paediatric CM-I is a challenging cohort, often due to young age and a lack oflanguage skills. There is a heavy reliance on radiological findings. Whilst FVRA has previously beenreported to be of value as a determinant of clinical severity in adult and paediatric patients, wefind this measurement is of dubious value in our retrospective cohort.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0033
Endoscopic foramen magnum decompression for pediatric Chiari malformation
type Ⅰ
Tomoru MIWA1, Kento TAKAHARA1, Masahiro TODA1
1

Neurosurgery, Keio University, Tokyo, Japan

Introduction : The suboccipital midline incision line tends to remain as a conspicuous wounddepending on its length and degree of scarring. In this study, we investigated whether effectiveness of
decompression and shortening of the incision line length can be achieved by using neuroendoscopy
for foramen magnum decompression (FMD) in pediatric Chiari malformation type I cases.
Material & Methods : Twelve pediatric FMD cases (6-17 years old). The skin incision line wasset at 23 to 35 mm and about 2 cm caudal from the inion, so that it would within the hairline of the
suboccipital region. The range of FMD was 25 to 30 mm square and C1 laminectomy was also
performed. Dural plasty were performed in all cases. During the operation, 4mm rigid endoscope
was freely grasped and the operative field was expanded as if lifting the skin to secure a sufficientfield of view.
Results : In all cases, the symptoms improved after surgery, and no perioperative complications
were observed. Four patients with extensive syringomyelia showed postoperative shrinkage. The
length of skin incision was 29.6 mm (23-40) on average. Before this series, 5 pediatric cases aiming
for cosmetic shortening without using endoscopes had an average length of 54.6 mm (45-60), and an
average shortening of 25 mm was obtained with using of the endoscope.
Conclusions : Under the neuroendoscope, the skin incision line could be shortened, and safe andsufficient decompression without complication was possible. In addition, the skin incision could be
kept well within the hairline and the patient’s cosmetic satisfaction could be improved.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0067
Earlier onset of Chiari malformation in children and its anatomical complexity.
Ryo ANDO1
1

Pediatric Neurosurgery, Chiba Children’s Hospital, Chiba, Japan

Introduction : Anatomical interpretation for Chiari malformation (CM) in pediatric population is a key
factor for successful treatment, however surgical strategy is still under debate.
Material & Methods : The author retrospectively analyzed our experience of pediatric CM from 2010
to 2023, regarding clinical onset and presentations, morphological data, and outcomes. Syndromic
craniosynostosis and spina bifida were excluded from this study.
Results : Ten patients were included. Two patients incidentally found at the average age of three
years were just conservatively followed. At the average age of 8.5 years, tonsillar descent was
spontaneously resolved. The other eight surgically treated patients were divided into two group basedon the onset age. Five patients with the earlier onset under age of ten years all had syringomyelia
with motor dysfunction or scoliosis. Three required foramen magnum decompression (FMD) withtonsillectomy and one underwent shunt to achieve syrinx deflation. On the later onset group over ageof ten years, all three had lifestyle-limiting headache. Two were treated with FMD and duraplasty forsyrinx deflation and the other one needed tonsillectomy for decompression of brain stem. Anatomicalfactors were analyzed on these three groups. Conservative group had lager clivo-axial angle (CXA)(>130°) and longer Klause index(>30mm), while earlier onset group had smaller CXA(<125°), withshorter Klause index(<25mm). Later onset group also had smaller CXA(<125°), however they tends
to have longer Klause index(>30mm).
Conclusions : Still limited number of patients, the earlier onset group tends to have anatomicallysevere morphology of posterior fossa. Cerebellar tonsillectomy can be a reasonable option for
posterior decompression in such population.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0072Autonomic dysfunctions presented after surgery for Chiari 1.5: A case reportand review of the literature
Kenichi NISHIYAMA1, Asako TOMII2
1

Neurosurgery, Niigata Medical Center, Niigata, Japan,
Endocrinology And Diabetes, Niigata Medical Center, Niigata, Japan

2

Introduction : According to the literatures, brainstem compression from hindbrain herniation may
lead to dysfunction in the area of the solitary nucleus and the dorsal motor nucleus or vagus nerve
in Chiari 1 patient. Presenting autonomic dysfunction were improved after decompressive surgery insuch cases. We report a Chiari 1.5 case with dysautonomia presented after successful operation.
Material & Methods : A 19-years-old girl presented with more than three years history of progressive
symptoms as follows: extremities’ sensory impairments, myoclonus, ataxia, dysuria and sweating
abnormality. MR-images demonstrated hindbrain herniation with elongation of medulla oblongata(MO) and syringomyelia. Foramen magnum decompression, C1 and C2 laminectomy with duraplasty
was successfully completed. Although pre-operative symptoms except for sweating abnormality
was improved immediately after surgery, she gradually suffered general fatigue, attach-wise episodeof getting stuck with blunted response and orthostatic intolerance a couple years later. Relatively
hypotension and hypoglycemia were determined during that condition. She has been treated
symptoms during more than ten years.
Results : Autonomic symptoms, such as syncopal episodes and sinus bradycardia were consideredby direct brainstem compression, otherwise the children (presumably the dorsal motor nuclei of thevagus) were extremely sensitive to changes in regional intracranial pressure. Symptoms presented
in our reported case are considered dysautonomia. Morphological changes of MO might alter thephysical characteristics of the solitary nucleus, the dorsal motor nucleus and the reticular formation
after decompressive surgery.
Conclusions : A case of Chiari 1.5 with dysautonomia after surgery was reported. The pathogenesis
was assumed to changes in form and physical characteristics of MO.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0076
Sleep apnea in patients with achondroplasia associated with foramen magnum
stenosis.
Nobutoshi KUMAGAI1, Kenichi USAMI1, Hideki OGIWARA1
1

Neurosurgery, National Center For Child Health And Development, Tokyo, Japan

Introduction : Sleep apnea is frequently associated with foramen magnum stenosis in patients withachondroplasia and considered a cause of sudden death. In this study, we evaluated the resultsof polysomnography (PSG) before and after surgery in patients who underwent foramen magnum
decompression at our hospital to elucidate the effectiveness for sleep apnea.
Material & Methods : PSG, magnetic resonance imaging (MRI), and otolaryngeal fibroscopy werereviewed in 22 patients with achondroplasia who underwent FMD at our hospital between 2016 and2022.
Results : Preoperative upper airway stenosis by fibroscopy was not found in 8 patients, mild in 10
patients, and not evaluated in 4 patients. AFMS (Achondroplasia Foramen Magnum Score) on MRI
was AFMS1 in 2 patients, AFMS2 in 4 patients, AFMS3 in 13 patients, and AFMS4 in 3 patients. The
Apnea Hypopnea Index (AHI) values on PSG were within the threshold (<5) in 8 patients, mild (5to 15) in 10 patients, moderate (15 to 30) in 3 patients, and severe (30 or more) in 1 patient. Twelve
patients had predominance in central apnea in the AHI, 7 patients had predominance in obstructive
apnea. Comparing preoperative and postoperative AHI of PSG in 22 patients, 18 patients showed
improvement in postoperative AHI (81.8%). Of the 14 patients with a preoperative AHI of 5 or higher,
10 patients (71.4%) showed at least one level of improvement.
Conclusions : FMD is considered to be effective for improving sleep apnea in patients withachondroplasia associated with foramen magnum stenosis.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 4: CVJ

A-0187
Surgical instrumentation in the pediatric craniovertebral junction: trick of thetrade
Shih-Hung YANG1, Meng-Fai KUO1
1

Neurosurgery, National Taiwan University Hospital, Taipei, Taiwan

Introduction : The craniovertebral junction (CVJ) is subject to various pathological processes, which
often result in neural compression or skeletal instability. CVJ instrumentation is challenging in thepediatric population. We report our experience in the National Taiwan University Hospital.
Material & Methods : During 2008-2022, twelve patients aged between 4 and 20 years (median= 11) underwent 14 instrumentation procedures involving the CVJ. Common etiologies were Down
syndrome and os odontoideum. Intraoperative C-arm were used in all procedures, three of which
utilized O-arm in addition. Hardware included two occipital plates, fifteen C1-2 transarticular screws,
five C1 lateral mass screws, four C2 pars screws, one C2 pedicle screw, two C2 sublaminal wiring,and one anterior plate with C2 dens-C3 screws. Bone grafts included 8 ribs and 5 posterior iliac crest
autografts, and one ulnar allograft. Follow-up period ranged from 1.5 to 5 years.
Results : All 12 patients had solid fusion, and neurological improvement. All 15 transarticular screws,
diameter of which were 3.0 mm in 7 and 4.5 mm in 8, remained intact during follow-up. Post-operative
CT revealed medial wall breach of the C1 lateral mass by 2 transarticular and 1 lateral mass screws
without spinal cord comprise. The three mal-positioned screws were among the 16 screws placed by
C-arm control, while all 9 screws by O-arm control were in acceptable position.
Conclusions : Instrumentation in the pediatric upper cervical spine is feasible. Modificationof operative strategies, including cannulation with smaller screws and combined 2D and 3D
intraoperative image control can enhance the accuracy of hardware placement in the younger
population.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0174Growth of bony spur after early foramen magnum decompression forachondroplasia patients
Jihoon PHI1, Tae-Joon CHO2, Jung Min GO3, Seung-Ki KIM1
1

Pediatric Neurosurgery, Seoul National University Children’s Hospital, Seoul, Korea, Republic of,
Orthopedics, Seoul National University Children’s Hospital, Seoul, Korea, Republic of,
3
Pediatrics, Seoul National University Children’s Hospital, Seoul, Korea, Republic of2

Introduction : Patients with achondroplasia have small foramen magnum and narrow craniocervicaljunction that make them vulnerable to spinal cord injury and even sudden death due to respiratory
failure. Foramen magnum decompression (FMD) is indicated for symptomatic patients and some
asymptomatic patients with severely narrow foramen magnum.
Material & Methods : From 2012 to 2022, 45 patients with achondroplasia received FMD for relieving
the craniocervical stenosis in early ages before 2 years. Their clinical and imaging follow-up data
were reviewed.
Results : Most of the patients got free of further neurological deficits after FMD. However, 3 patientslater developed new neurological deficit or appearance of new lesion on follow-up imaging years
later. Growth of bony spurs from the wall of decompressed corridor was found in the patients.
Removal of the bony spur relieved the symptoms and prevented further injury.
Conclusions : Early FMD for the vulnerable group clearly provides protection from spinal cord injury
for achondroplasia patients, but it carries a small but evident risk of bony regrowth in later years.
Regular follow-up with imaging studies is required for patients who received FMD in infancy.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0013
Establishment of Intraoperative Monitoring Methods for Pediatric Spinal Cord
Surgery Analysis of the Effects of General Anesthesia Methods on InfantsMichihiro KURIMOTO1, Tomoki NAWASHIRO1, Masamune NAGAKURA1, Mihoko KATO1
1

Neurosurgery, Aichi Children’s Health And Medical Center, Obu, Japan

Introduction : Intraoperative monitoring of somatosensory evoked potentials (SEPs), motor evoked
potentials (MEPs), and bulbocavernosal reflexes (BCRs) has been developed for spinal lipoma
surgery, however, it has been reported that in many cases, particularly in children up to infancy, falsenegative monitoring results and ineffective measurement cannot be obtained due to various factors
such as the localization of motor cortex from the body surface, differences in neural thresholds, andthe effects of general anesthesia.
Material & Methods : In collaboration with the Department of Anesthesiology, Aichi Children’s HealthCare Center, we have conducted a crossover study to investigate the effect of general anesthesia
on intraoperative monitoring as a preliminary study for the above purpose. The Japanese Societyof Anesthesiology has published a “Practical Guide for Anesthesia Management during MEP
Monitoring,” which recommends propofol alone or in combination with a small amount of inhaledanesthetics as general anesthesia. In response to this, we developed a study design to measure
MEP, SEP, and BCR in patients under 2 years of age who underwent scheduled spinal surgery at our
hospital, with propofol and a small amount of inhaled anesthetics combined with monitored expiratory
anesthetic concentration, and then with propofol alone after a washout time.
Results : The results showed an age-adjusted MAC=0.2, indicating that even small doses of inhaledanesthetics had an effect.
Conclusions : In particular, we report that intravenous general anesthesia (TIVA) tended to provide amore stable monitoring environment for MEP measurements. Next, a prospective study is underway
to examine the effects of monitoring techniques and equipment.

39

4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0032
Continuous Administration of Dexmedetomidine Reduce Intraoperative
Neuromonitoring in Infants.
Minami SASAKI1, Hiroshi KOKUBUN2, Hiroshi MIYANABE3, Yuji KITAMURA2,
Tadashi MIYAGAWA1
1

Pediatric Neurosurgery, Matsudo City General Hospital, Matsudo, Chiba, Japan,
Anesthesiology, Pediatric Anesthesiology, Matsudo City General Hospital, Matsudo, Chiba, Japan,
3
Clinical Examination, Matsudo City General Hospital, Matsudo, Chiba, Japan
2

Introduction : There are several reports of the effects of using dexmedetomidine (Dex) on
intraoperative neuromonitoring (IONM) in adults and older children. However, there is no consensus
on it, and there are few reports of infants. This study aims to evaluate the effect of Dex on IONM
during infant surgery.
Material & Methods : This study included 46 infants who underwent spinal code untethering undergeneral anesthesia with propofol and Dex; intraoperative bulbocavernosus reflex (BCR) monitoring
was performed. BCR amplitude at each surgical stage (T1: at dura incision, T2: at dura closure, T3:
at the end of monitoring) was compared with BCR amplitude at the start of surgery (baseline). Thenthe relationship between Dex dosage and BCR amplitude was predicted. Multiple regression analysis
was also used to examine additional independent variables affecting BCR amplitude. In addition,
the correlation between blood Dex concentrations and BCR amplitudes was determined using
pharmacokinetic simulations of Dex.
Results : The ratio of BCR amplitude at each surgical stage to baseline was baseline (100)>T1(67.3±31.4)>T2 (47.8±33.7)>T3 (32.6±26.4). BCR amplitude in T3 was negatively correlated with
DEX dose. Furthermore, the only factor affecting T3 amplitude was the dose of Dex. Moreover, theBCR amplitude significantly decreased at Dex blood concentrations of 0.6 ng/ml or higher, leading toan unreliable IONM.
Conclusions : This study showed that BCR amplitude could be attenuated depending on the Dex
dose. It is helpful to develop age-appropriate dosages based on blood concentration simulations of
Dex for reliable IONM, especially in infants.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0042
Spinal instrumentation surgery in paediatric patients: a new era in our local
experience
Mei Sin LIM1, Fadzlishah JOHANABAS1, Azmi Bin ALIAS1, Thinesh KUMARAN1
1

Neurosurgery HKL, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Introduction : Spinal instability and deformities in paediatrics has always been a major concern
given the varying different pathologies and this complexity often becomes challenging for surgicalcorrection and instrumentation. However, there is a growing shift towards the direction of arthrodesis
in recent years largely due to the evolving understanding of the anatomy, the dynamic nature of thediseases and the biochemical of the developing and immature spine.
Material & Methods : In this retrospective study, we evaluate our initial cohort of spinal surgeries with
instrumentation in paediatric patients aged below 10 years from September 2020 to September 2023,
a consecutive series of five spinal surgeries with instrumentation performed in Hospital Tunku Azizah,
Kuala Lumpur. The surgeries performed; spinal instrumentation was placed at the cranio-cervicaljunction (C0-C2; 3 cases), subaxial cervical spine (C3-C7;1) and thoracic spine (T1-T11;1). We
outline our surgical indications, criteria for case selection, strategic placement of anchoring points
and limitations in paediatric spinal interventions.
Results : We performed three atlanto-axial arthrodesis, one cervical sub-axial arthrodesis, and one
thoracic arthrodesis. The average of fused levels was 2.5 (ranging from 2-4) with a consolidation rateof 96%. All our patients healed without major complications and we had a follow up with the patient
using dynamic X-rays and 3D reconstruction CT scan after 6months to 1 year after surgery to look forcomplete fusion and evidence of instabilities.
Conclusions : Although most authors agree that instrumentation can achieve stable fixation, its
implementation often comes with greater risk of complications. Our recent local experiences seem todemonstrate exceptional outcomes in arthrodesis

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0117
Fourth ventricle stent placement for treatment of refractory syringomyelia inchildrenPeng SUN1, Mading ZHOU1, Yutong LIU1, Jianxin DU1, Gao ZENG1
1

Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China

Introduction : Sringomyelia is a disorder characterized by the presence of cystic cavities in the
spinal cord. It occurs most commonly in association with Chiari malformation but also can be theresult of intramedullary or posterior fossa tumor, spinal dysraphism and spinal arachnoiditis. Fourth
ventricle stenting (FVS) could ensure the CSF flow from the fourth ventricle, which might represent aneffective approach to achieve syringomyelia relief.
Material & Methods : We have reviewed eleven cases of syringomyelia children who received
FVS implantation from November 2021 to February 2023. Each of the patients underwent foramen
magnum decompression. The ventricular catheter of an Ommaya reservoir (Medtronic, Inc.) was used
as a stent. Cervical MRI rechecks were routinely done three months later, and the clinical symptoms
were followed up.
Results : Eleven children received FVS, including five boys and six girls, aged from 12 months to
10 years, with a mean age of 5.6 years. Ten patients were Chiari malformation and the other patientdeveloped syringomyelia following posterior fossa tumor surgery. No major complication occurred.
During the follow-up time with a mean of 13.8 months, one patient had syringomyelia recurrence
19 months after operation and she received second foramen magnum decompression with partial
tonsil resection. The syringomyelia of the other ten patients were all attenuated, as observed on thereexamination MRI images.
Conclusions : FVS is an effective strategy to treat refractory syringomyelia, not only in patientswith Chiari malformation, but also in other conditions that affect the free flow of CSF from the fourth
ventricle to spinal subarachnoid space.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0120Laminotomy Technique for Long Segment Pediatric Spinal Tumors: A Ten Year
Case Series from a Single Center Experience
Nadiah FUAD1, Fadzlishah JOHANABAS1, Azmi Bin ALIAS1
1

Department Of Neurosurgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Introduction : Spinal cord tumors are rare in adults and even rarer in pediatrics. In our practice,majority of pediatric spinal tumors involve long segments, encompassing more than three spinallevels. Preserving the posterior ligamentous complex is crucial to prevent progressive kyphosis.This
study introduces the laminotomy technique with preservation of the posterior ligamentous complex.
Material & Methods : A midline skin incision is made at the designated level, followed bysubperiosteal dissection until the medial border of the laminae-facet junction. Laminotomy isperformed in a cranio-caudal manner, with cranial extension to the non-pathological level using ahigh-speed drill with the footplate positioned perpendicular to the arch of laminae and ventral to theligamentum flavum. The supraspinatous and interspinous ligaments are cut at the most caudal levelto facilitate a one-piece opening, and the laminoplasty segments are lifted in the cranial direction to
fully expose the spinal cord. After tumor resection, the laminoplasty segments are repositioned, andsuture laminoplasty is performed. Slit holes made halfway to the diploe and receiving bone edges
are created using a 1-mm high-speed drill to prevent retraction and injury to the venous plexus. The
laminaes are secured with 3/0 Prolene sutures. Paraspinal muscles are re-approximated, and surgicalwounds closed.
Results : This technique was applied in 53 cases of pediatric spinal tumors over a decade.
Postoperative X-rays revealed no evidence of progressive kyphosis during follow-up.
Conclusions : The laminotomy technique with preservation of the posterior ligamentous complex
for long segment pediatric spinal tumors has proven to be beneficial in our practice, effectively
preventing progressive kyphosis.

434th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0122
Early Experience in Pediatric Spine Infection : 4 years Follow Up PediatricScoliosis Patient caused by Tuberculous Spondylitis with Posterior Stabilization
Astri AVIANTI1, Subrady LEO SOETJIPTO SOEPODO2, Astri AVIANTI1, Ita KARTIKA1,
Aswin SURYA WIDJAJA1, Satyanegara SATYANEGARA1
1

Neurosurgery, Satyanegara Hospital, Jakarta Utara, Indonesia,
Neurosurgery, Primaya, Tangerang, Indonesia

2

Introduction : Tuberculous spondylitis in children is common illness in country with a high prevalenceof Tuberculous infection. It generates massive desctruction of vertebral body and the intact posterior
column. The choice of treatment for spinal infection consist of surgery, bracing, nutrition, antibiotic oranti tuberculous agent. This treatment, strategy and follow up given for 5 years old girl with scoliosis
caused by Tuberculous Spondylitis She had weakness on lower extremities, back pain during her
activities and progressive kyphosis. The posterior stabilization done and revision in the next three
years.
Material & Methods : The method of the treatment is based on the etiology. Infection must be treatedby the anti tuberculous agent for 12 months and also posterior approach’s surgery for debridement,
abcess evacuation, laminectomy and stabilization with pedicle screw. The patient received several
treatments and observations such as bracing to generate maturity of the skeletal maturity developedand exercises. After the revision surgery, observation still remain due to her development and growth.
Results : Surgery and rehabilitation can make a good correction for the scoliosis. Anti tuberculous
agent treated not only for the lungs infection but also for the vertebrae and absess in psoas muscle.
The pain and walking disturbance disappear, she felt pain in the back in the next 3 years so we did
the revision surgery.
Conclusions : Multidiscipline treatment is needed to gain an optimal treatment for pediatric scoliosis
patient such as bracing, exercises and also radiological examination for the continued monitoring
phase. The follow up still continue until adolescence time for postural balance and stability.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0159Multiple Tarlov cysts in a young child patient
Yuki KURANARI1, Tomoru MIWA1, Mariko FUKUMURA1, Masahiro TODA1
1

Neurosurgery, Keio University School Of Meidicine, Tokyo, Japan

Introduction : Symptomatic Tarlov cysts in pediatric patients are extremely rare. Treatment methods
for Tarlov cysts are still controversial. We report a rare young child case of multiple Tarlov cysts withurinary and fecal incontinence, nocturnal enuresis, and abnormal lower abdominal sensations.
Material & Methods : A 5-year-old girl presented with a 1-year history of urinary and fecal
incontinence and nocturnal enuresis. She also had abnormal lower abdominal sensations.
Radiological studies revealed bilateral cystic lesions at the levels of S2 and S3 (total of four cysts).
Results : Microsurgical decompression for all cysts was performed without any nerve root injury.
After the operation, urinary and fecal incontinence and abnormal lower abdominal sensation were
improved. There has been no re-operation in the three years since the first operation.
Conclusions : To the best of our knowledge, this is the first pediatric case report with multiple Tarlov
cysts. The surgical treatment of Tarlov cysts is optional in symptomatic cases. Our case suggests thatmicrosurgical decompression is a safe and efficacious option for multiple Tarlov cysts in pediatricpatients.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 5: SPINE

A-0171The Successful separation of conjoined spinal cords in pygopagus twins; Acase report and review of literature
Chisato YOKOTA1, Naoki KAGAWA2, Yohei BAMBA4, Yuko TAZUKE3, Yasuji KITABATAKE3,
Tomoyoshi NAKAGAWA2, Ryuichi HIRAYAMA2, Hiroomi OKUYAMA3, Haruhiko KISHIMA2
1

Neurosurgery, Suita Munincipal Hosipital, Suita-city, Japan,
Neurosurgery, Osaka University Graduate School Of Medicine, Osaka, Japan,
3
Pediatric Syegery, Osaka University Graduate School Of Medicine, Osaka, Japan,
4
Neurosurgery, Osaka Rosai Hospital, Sakai-city, Japan
2

Introduction : Conjoined twins represent a rare congenital malformation. Pygopagus twins are fusedat the sacrumand perineum, with union of the spine. We report a successful separation of a uniquecase of pygopagus twins sharing a U-shaped spinal cord.
Material & Methods : The 6-month-old male pygopagus conjoined twins, who were diagnosedin the prenatal period, underwent separation. They had a single dural sac containing a U-shaped
continuous spinal cord; their filum terminale appeared completely fused and the anatomical borderof the spinal cord was not distinguishable. A triggered electromyogram (tEMG) was used to detect
functional midline cleavage of fused spinal cord. The nerve roots were subdivided into bundles as
small as possible, and sequentially stimulated to distinguish which belonged to one twin versus theother.
Results : All nerve roots were subdivided into individualnerve fibers and separated sequentially
one by one on the boundary where both electromyogram activities were minimized. The twins wereseparated, and recovered with no lower limb neurological deficits or walking impairment for 5 years.
Conclusions : Pygopagus twins with a conjoined spinal cord can be expected to have a good longterm functional prognosis if successfully separated. Intraoperative tEMG is useful in spinal separation
surgery for twins with a conjoined spinal cord.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0049The Significance of Neurosurgical Treatment for Abusive Head Trauma Comparison of Outcomes with Simple Accident Cases –Takashi ARAKI1, Jun KURIHARA2
1

Emergency And Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama,
Japan, 2Neurosurgery, Saitama Children’s Medical Center, Saitama, Japan

Introduction : The outcome of children with severe traumatic brain injury (TBI) caused by Abusive
Head Trauma (AHT) is compared with the outcome of TBI with simple accident and therapeuticstrategies will be discussed.
Material & Methods : 38 patients who underwent decompressive craniectomy (DC) in 100 cases ofsevere TBI caused by simple accident under 16 years of age who admitted to the hospital (S group)and 50 cases who was diagnosed with AHT (A group) which required DC were included to this study.
Patients’ ICP course, treatment, outcome was retrospectively analyzed.
Results : Poor prognosis by King’s Outcome Scale for Closed Head Injury score (KOSCHI) was morecommonly seen in A group than in S group (P <0.05) and longer hospitalization was required. The
ICP value was markedly decreased by DC in both groups, which was not associated with mortality.
The post-op ICP management was required (A group; 3.1 ± 1.7, S group; 10.7 ± 5.4) was longer in
S group (P <0.01). Parenchymal atrophic change and posttraumatic seizure were commonly seen in
A group. Subdural space enlargement was more likely observed in A group but, recently, most of thecases completely resolved with a combined prescription of tranexamic acid and Goreisan.
Conclusions : Extensive and rapid progression of atrophic change in brain parenchyma wasremarkable in A group, which suggested specific pathophysiology of AHT. Although the outcome of A
group is extremely pessimistic compared with S group, there have been reports on the effectivenessof rehabilitation, and treatment with the expectation of improving functional prognosis is important.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0045
Issues related to organ donation from pediatric brain-dead donors in Japan:
Consideration and efforts regarding the prohibition of organ donation fromabused children.
Takashi ARAKI1, Jun KURIHARA3
1
Emergency And Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama,
Japan, 2Traumatology, Saitama Children’s Medical Center, Saitama, Japan, 3Neurosurgery, Saitama Children’s
Medical Center, Saitama, Japan

Introduction : Since the revision of the law on organ transplantation in 2010, the number of organ
donations from pediatric brain-dead patients in Japan has slightly increased, but is far behind thenumber in developed countries. Among the issues that have been pointed out in Japan’s organ
donation system, the prohibition of organ donation from abused children is a unique and unparalleledin other countries.
Material & Methods : The “Development of Educational Programs for Organ Donation from Children”
research group has been conducting: 1) a study on measures to exclude abused children andthe establishment of a support system; 2) a study on the occurrence of terminally ill patients andconfirmation of their and their families’ wishes; 3) a study on practical ways of family care.
Results : In response to the request for “organ donation from children (clarification of procedures to
exclude abused children)” by the Organ Transplant Committee of the Disease Control Subcommitteeof the Ministry of Health, Labour and Welfare, our group have pointed out the inconsistencies in thecontents of the Guidelines for Enforcement of the Law, the Questions and Answers Manual for Organ
Donation Procedures, and the Manual for Excluding Abused Children, and presented a roadmap for
how to cooperate with multidisciplinary teams.
Conclusions : It was found that no country other than Japan has prohibited organ donation fromabused children in principle, and that many countries respond to this issue in cooperation withmedical examiners and forensic physicians. The development of pediatric transplantation medicine inJapan in accordance with international standards is expected.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0004The consequences of the COVID-19 pandemic on pediatric neurosurgery in the
Middle East: an experience from a pediatric trauma hub
Reza TAHERI1, Mohammadsadegh MASOUDI1, Nazanin HOSEINI1,
Sepehr KHADEMOLHOSSEINI1, Pardis SHAHABINEJAD1, Fatemeh MOVAHEDI1,
Saber ZAFARSHAMSPOUR1
1

Neurosurgery, Shiraz University Of Medical Sciences, Shiraz, Iran, Islamic Republic of

Introduction : Few studies from the poor world examine how neurosurgeons view the epidemic andhow neurosurgery practice has altered, but none from the Middle East. Our academic Level I Pediatric
Neurosurgery Center admits more than 700 children a year for neurosurgical problems and supports
20 hospitals in the region. This study examined how COVID-19 affects pediatric neurosurgicaldiseases. Researchers expected the outbreak would have little influence on neurosurgical cases or
epidemiology. The goals were to compare daily incidence, patient demographics, injury patterns, andcare strategies between the 2020 pandemic and the previous year.
Material & Methods : Researchers conducted a retrospective examination of our institution’s
prospectively recorded registry with IRB approval.The study’s major outcome variables wereincidence and patient characteristics, including age (continuous), gender (nominal), admission
context (emergent/urgent versus elective), and COVID-19 test status (dichotomous).
Results : Before the pandemic, the fewest patients admitted to our facility in a month was 31, but
afterward it was 20. During the pandemic, hospitalizations from car accidents dropped (20.3% in
pandemic vs. 34.4% in pre pandemic). Patients were also pedestrians hit by a vehicle during andbefore the pandemic. 248 epidemic victims needed neurosurgery (54% ).
Conclusions : Neurosurgeons in impoverished nations can’t avoid the COVID epidemic and must
adapt to the changing healthcare environment. If referrals and loco-regional transfers reducesignificantly, pediatric neurosurgery tertiary-care facilities can be better placed to handle patientsduring times of severe resource allocation. A move toward outpatient care, needed by the epidemic,
may reduce hospital admissions and associated costs.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0017
Bone flap resorption following pediatric autologous cranioplasty andassociated factors.
SUPACHAI SRICHANTHA1
1

Division Of Neurosurgery, Department Of Surgery, Kalasin Hospital, Kalasin, Thailand

Introduction : Children made up roughly 4.1% of TBI-related deaths. The most frequent surgery is
a decompressive craniectomy (DC), which is followed by a cranioplasty (CP), which has a high rateof surgical complications. Therefore, the goal of this study is to assess the risk factors for bone flap
resorption (BFR).
Material & Methods : In a retrospective analysis conducted at Kalasin Hospital, Thailand. 22 patients
who underwent CP with autologous bone flaps from October 2020 to May 2023. Data were collectedutilizing the medical records and CT brain.
Results : Using an autologous bone flap, 22 patients were enrolled in the trial. The median age was
14.77 (5-20) years. The most frequent reason for DC was TBI. The median time between DC and CP
was 90 days (72-169). The median bone flap size was 73 cm2 (20-150). 4 patients (18%) experienced
surgical complications. The most frequent complications were BFR (13.6%) which required repeat
surgical intervention, Implant displacement (4.5%), and hydrocephalus (9.1%) which one patient
required a VP shunt. We observed that large bone flaps (p = 0.035), bone flap size that was larger
than 115 cm2 (p = 0.023), and contusional hemorrhage at first admission (p) were associated with ahigher rate of BFR.
Conclusions : Because of the patient’s financial situation and cosmesis, autologous cranioplasty was
primarily performed in our hospital. Therefore, it is important to choose a good patient to avoid BFR.
Finally, to track the BFR, the patients with large bone flaps and contusional hemorrhage should also
be closely and persistently followed up.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0025Use of MLC 901 (NeuroAid) in Traumatic Brain injury in Children- Patient Series
Giat Seng KHO1
1

Neurosurgery, Hospital Tuanku Ja’afar Seremban, Seremban, Malaysia

Introduction : Traumatic Brain Injury (TBI) results in acute and chronic sequalae involving structuraland functional impairments especially in children. This leads to significant disability which may affectchild’s development and adaptive functions. In TBI, both elderly patients and children have a high ofrisk of developing long term disability, which unfortunately, have no proven treatments. MLC901(NeuroAiD) is a combination of natural herbal formulations with origins from Traditional Chinese
Medicine which has shown to be safe and aid in neurological recovery after brain injuries.. Thereis an existing knowledge gap on the use of MLC901 for paediatric age group as the evidences forstroke, TBI and Cognition included all adult patients hence, these cases were presented to described
potential role of MLC901 in severe traumatic brain injury in children.
Material & Methods : Recruited two 11yo boys completed 6 months of NeuroAid, and subsequent
6 months follow up. Neurological imorovement and Mini Mental State Examination were performed
during the follow up.
Results : There is a potential role of MLC901 (NeuroAiD) in severe traumatic brain injury amongchildren in both subacute and chronic cases. Our study is limited as being a case series, the extent
of improvement is variable which may be difficult to quantify. Lack of guidance for effective dose inchildren. The dosage was based on the dosage of 60 kg adult at 10 kg weight per one capsule.
Conclusions : In conclusion, both cases showed the safety and potential role of NeuroAiD in
Traumatic Brain Injury in children.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0047
Consideration on the effect of coagulopathy in perioperative period and theusefulness of the bleeding index in prognosis prediction of severe traumaticbrain injury in children
Takashi ARAKI1
1

Emergency And Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan

Introduction : Children have different features in many respects from anatomical and physiologicallevels compared to adults. Craniotomy itself can exacerbate the pathophysiology of children in severe
traumatic brain injury with complicated intracranial pressure and coagulopathy, we will consider pitfall
at the perioperative period.
Material & Methods : 54 patients with TBI who were admitted to PICU during the 23 months fromJanuary 1, 2016 to November 30, 2017 were included. All patients were divided into two groupsof surgical treatment group (S group: n=16) and conservative treatment group (C group: n=38),
and extraction of clinical parameters involved in outcome was attempted. In order to examine
the influence of coagulation abnormality on intraoperative bleeding volume, bleeding index was
calculated and the effectiveness of index in surgical strategy was examined.
Results : The mean age of group S was 4.1 ± 3.2 years, and that of group C was 7.7 ± 3.9 years.
In comparison between two groups, the S group had a tendency of low GCS (p = 0.0036), high ISS(p <0.001) and high D-dimer level (p <0.01). There was no significant difference between the twogroups in the outcome. In group S, the amount of intraoperative bleeding and the bleeding index of
ASDH were both significantly higher than those of AEDH.
Conclusions : Craniotomy for severe TBI is likely to be chosen for children with coagulopathy. ASDH
has a higher bleeding index, a large amount of bleeding that promotes hypotension is expected.
Preopetative transfusion and intraoperative hemostasis are essential that do not induce poor outcome
in children.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0063
Anatomic Location Trends in the Occurrence of Pediatric Head Trauma
Taijun HANA1, Shinsuke YOSHIDA1, Tomoko IKEMOTO1, Kengo KURIHARA1, Soichi OYA1
1
Department Of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama,Japan

Introduction : In the field of pediatric neurosurgery, pediatric head trauma (PHT) is one of the major
topics, and there has been ongoing exploration for optimal head protection strategies for children.
Nevertheless, detailed analysis of the locational tendency of PHT has not yet been conducted. Since
we recognized specific trends in the location of PHTs of the children receiving medical services, we
conducted a study to analyze it.
Material & Methods : Within three-years duration, we analyzed 152 PHTs in 146 patients aged 0-14
years who were examined in our outpatient clinic. We categorized the pediatric head into 18 regions
and statistically analyzed those locational frequencies of the registered PHTs.
Results : Male patients outnumbered females (87:59) with significance (p=0.025). Median age
was 2 years and 3 months; 69.9% (102/146) were under 5 years old. Majority of PHTs (65.7%) weresignificantly concentrated in the “headband area (HBA)”, where tennis players wear headbands(p=0.001). Frequent-injury sites varied by age, and there was a tendency for younger age groups tobe more susceptible to injuries in the frontal region compared to the occipital region. Those under
4 had notably high injury frequency in the central forehead region, occurring 4.6 times more than
expected based on area proportion (p=9.421e-13).
Conclusions : While PHT predominantly occurs in the HBA, its frequency and location differ basedon age. Interestingly, there are narrow regions on the head where children of specific age groups
are particularly susceptible to PHT. Considering age and high-frequency PHT sites is important foreffective head protection strategies in the pediatric neurosurgery field.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0064
A case of non-traumatic subdural hematoma associate with Jacobsen’s
syndrome
Tomoki NAWASHIRO1, Masamune NAGAKURA1, Michihiro KURIMOTO1, Mihoko KATO1
1

Neurosurgery, Aichi Children’s Health And Medical Center, Obu, Japan

Introduction : Jacobsen’s syndrome (JS) poses a significant risk of hemorrhagic complications,particularly the severe Paris-Treussaud hemorrhagic disorder, which can include life-threatening
intracranial hemorrhages, albeit infrequently reported. Managing patients with JS who require
anticoagulant therapy presents a delicate balance between achieving hemostasis and anticipating
potential complications, which may require consideration of discontinuation of anticoagulant
treatment.
Material & Methods : In this case, a 3-year-old boy diagnosed with JS and a history of severecongenital heart disease necessitating mechanical valve replacement was prescribed warfarin andaspirin. These anticoagulants were temporarily halted due to an elevated PT-INR. Subsequently,
he developed a left subdural hematoma after a head CT scan prompted by frequent vomiting.
Treatment involved Prothrombin complex concentrate, Menatetrenone and blood transfusions, with
an emergency craniotomy required due to anisocoria. While a follow-up head CT showed no increaseof hematoma, anticoagulation therapy was cautiously resumed, targeting an INR range of 1.5-2.0.
Unfortunately, the hematoma expanded, leading to another treatment discontinuation. After a 10-day
period without antiplatelet therapy, anticoagulation was reintroduced with INR monitoring and frequent
CT scans. The patient required periodic blood transfusions due to persistent thrombocytopenia but
gradually improved and was eventually discharged.
Results : This case underscores the intricate management demanded by bleeding risks associatedwith JS.
Conclusions : Despite improvements in numerical coagulation function, bleeding remains
a significant concern. Therefore, a comprehensive assessment of the risk-benefit balance ofantithrombotic therapy is crucial in cases of hemorrhagic complications. In certain scenarios, as
demonstrated here, a comprehensive postoperative management strategy may be necessary toeffectively navigate these complex challenges.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0190Sports participation after neurosurgery in children
Ai MUROI1, Takao TSURUBUCHI1, Eiichi ISIKAWA1
1

Department Of Neurosurgery, Institute Of Medicine, University Of Tsukuba, Tsukuba, Japan

Introduction : There is little evidence or guidelines for physical activity in pediatric neurosurgicalpatients, and most neurosurgeons give advice to patients and families based on personal experience.
The aim of this study was to clarify the current status regarding sports participation in this group ofpatients in order to establish a return-to-learn and return-to-play guideline.
Material & Methods : Patients younger than 18 who underwent neurosurgical intervention were
included in this study. Medical records were reviewed retrospectively.
Results : There were 233 patients who underwent surgery during the period. The mean age atsurgery was 6.4 years. The mean follow-up period was 34 months. The procedures performed
were craniotomy in 135, burrhole surgery in 88, spine surgery in 64, and others in 12. Sixty-eightpatients had device implanted. According to medical records, 5 patients (2.1%) were admitted tothe emergency department for minor head trauma without further treatment. Thirty-nine patients(17%) were documented as playing sports outside of school sports. The sports included tennis andbasketball in 7, baseball in 5, swimming in 4, and soccer in 3. No patient reported head trauma due
to sports participation.
Conclusions : There is little evidence in the literature to support the safety and recommendationof sports participation for children after neurosurgery. This study demonstrate the rate of sports
participation in such patients was lower than that in the general population of the same age group,
however, the traumatic injury was uncommon. Large studies are required to establish evidence-based
guidelines.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 6: TRAUMA

A-0200
Neglected Chronic EDH Spinal in Pediatric Patient
Kadek Dede Frisky WIYANJANA1, Sri MALIAWAN1
1

Neurosurgery, Udayana University, Denpasar, Indonesia

Introduction : Chronic spinal epidural hematoma (CSEH) is a rare but potentially debilitating
condition that occurs when blood accumulates in the epidural space over an extended period. While
this condition has been well-documented in adults, its occurrence in pediatric patients remains
relatively underreported and neglected.
Material & Methods : A 10-years old female patient came with chief complaints of pain andweakness in both arms 3 months before hospitalization and worsened 2 days before admission.
Patient complained neck pain after log roll exercise and 1 week later patient had difficulty of grasping
objects. Neurologic examination revealed motor grade 2/5 followed with hypotonus and atrophy on
both distal upper extremities. T2-weighted MRI revealed oval-shaped hypointense lesion with grade
III canal stenosis on C5-C7. The patient underwent En Bloc laminotomy C5-Th1 and spinal EDH
evacuation. The patient was discharged after 5 days of hospitalization with improved motoric power.
Results : Common presenting symptoms of CSEH included back pain, neurological deficits, andprogressive weakness. Diagnostic delays were common, often due to the non-specific nature of
initial symptoms and the rarity of the condition in children. Surgical decompression, predominantly
laminectomy, was the mainstay of treatment, with notable improvements in neurological deficits
observed postoperatively.
Conclusions : Timely recognition and appropriate surgical intervention are crucial for achieving
positive outcomes in affected pediatric patients. Increased awareness among healthcare providers
and further research into the epidemiology, risk factors, and optimal management strategies forneglected CSEH in the pediatric population are essential to enhance early diagnosis and improve
patient outcomes.

564th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 7: CRANIOSYNOSTOSIS

A-0036
Management of patient with Crouzon’s syndrome with hydrocephalus, Chiarimalformation and tethered fatty filum
Giat Seng KHO2, Hsin-Hung CHEN2
1

Neurosurgery, Hospital Tuanku Ja’afar Seremban, Seremban, Malaysia,
Division Of Pediatric Neurosurgery, The Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan

2

Introduction : Craniosynostosis is a condition where one or more of the cranial sutures closed
prematurely, leading to abnormal head shape and potential developmental issues. Especially forpatient with Crouzon’s syndrome is 30% more likely will exhibit with progressive hydrocephalus as
the constant feature. In most cases of syndromic craniosynostosis, venous sinus obstruction and / orchronic tonsillar herniation were found, which diagnosis of chiari malformation was made, in view of
their syndromic figure, patient with skin stigmata, spinal cord pathology was always suspected.
Material & Methods : Recruited two patients with Crouzon’s syndrome with fatty filum, which
underwent surgical intervention for their underlying pathologies. Patient A without hydrocephalus andpatient B progressive worsening hydrocephalus with increased ICP signs
Results : Option of surgical treatment and timing of surgery always a debate in patient withmultiple morbidity, especially in these rare unreported cases. Patient A underwent craniosynostosis
surgery and detethering of fatty filum on the same setting. Patient B underwent endoscopic
third ventriculostomy (ETV) and detethering of fatty filum on the same setting too. Arranged
craniosynostosis surgery before one year old was planned for the patients. We suggest to proceedwith ETV prior to detethering procedure for these patients.
Conclusions : Surgical intervention planning with correct indication is the fundamental factor in
deciding the mode of action for the mentioned patients. The controversy may arise due to factors
such as patient’s age, the underlying cause of hydrocephalus, the success rate of ETV comparedto other treatments to other treatments like shunt placement, and potential risks associated with theprocedure.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 7: CRANIOSYNOSTOSIS

A-0097
Fro m Wre n c h o p e n to B u l g e o u t - E a r l i e r Wi d e r S u tu re c to my fo r
Craniosynostosis reduces the Surgical Invasiveness Shigeo KYUTOKU1, Atsuko HARADA2, Akinori ASAKA3, Nayuta HIGA4, Tatsuki OYOSHI5,
Koichi UEDA3
1

Division Of Reconstructive Plastic Surgery, Nara City Hospital, Nara, Japan,
Division Of Pediatric Neurosurgery, Takatatsuki General Hospital, Tahatsuki, Japan,
3
Department Of Plastic Surgery, Osaka Medical And Pharmaceutical University, Takatsuki, Japan,
4
Department Of Neurosurgery, Kagoshima University, Kagoshima, Japan,
5
Division Of Neurosurgery, Ichikikushikino Medical Association Neurosurgery Center, Ichikikushikino, Japan
2

Introduction : An incidence of craniosynostosis in Japan has not been high compared to Westerncountries, but the recent ‘baby’s head shape clinic’ campaign has found more patients in a muchsmaller age. An earlier diagnosis allows for optimal time treatment in a few months of age, andrequire to choose a suitable surgical technique.
Material & Methods : Procedure and clinical application: We have applied modified Jimenez
procedure (1998) for very early years of 38 patients with several types of craniosynostosis, in the past
7 years. Two-month-old girl of Pfeiffer syndrome was a first application in our unit, the reason wasthat we decided not to wait until 5 to 6 months, when the distractor device could be stably set on theharder enough bone, and thought we should take any step beforehand. The fused suture could be
cut by bone forceps or diamond drill, even scissors can be used, via 2 or 3 cm skin incision, underendoscopic support. This method has been used non-syndromic case as well.
Results : Although the experience was small, the results have been all good in natural volume
change and morphological correction by rapid growing brain.
Conclusions : The procedure proved to be another alternative, especially prior to posterior distractionof syndromic patients(23cases) in terms of positive and expedited control in an earlier surgicalmanagement, or possibly just one surgical treatment for a simple suture synostosis(15cases). The
earlier, the better with help of rapid growth period.

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Oral presentation 7: CRANIOSYNOSTOSIS

A-0109Neurocognitive Outcomes of Children with Craniosynostosis after Minimally
Invasive Strip Craniectomy
Joo Whan KIM1, Kyung Hyun KIM1, Ji Hoon PHI1, Ji Yeoun LEE2, Eun Jung KOH1,
Min-Sup SHIN3, Seung-Ki KIM1
1

Pediatric Neurosurgery, Seoul National University Hospital, Seoul, Korea, Republic of,Anatomy And Cell Biology, Seoul National University College Of Medicine, Seoul, Korea, Republic of,3Child And Adolescent Psychiatry, Seoul National University Children’s Hospital, Seoul, Korea, Republic of2

Introduction : Craniosynostosis involves early closure of one or more sutures, which is known to limit
normal cranium growth and interfere with normal brain development. Various surgical methods areused, ranging from minimally invasive strip craniectomy to more extensive whole vault cranioplasty.
This study aimed to evaluate neurocognitive outcomes five years after strip craniectomy in children
with craniosynostosis.
Material & Methods : A retrospective review of 95 craniosynostosis patients was performed. Patients
underwent strip craniectomy with postoperative orthotic helmet therapy. Neurocognitive assessment
was performed five years postoperatively. Clinical data, affected sutures and neurocognitive outcome
measures using the Korean Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition(K-WPPSI-IV) were compared between the suture groups.
Results : The number of patients in each suture group was 18 in the unicoronal group, 11 in thebicoronal group, 46 in the sagittal group, 12 in the lambdoid group, and eight in the multiple suture
synostosis group. The mean age at surgery was 4.5 months, and the mean follow-up period was 4.9
years. The Full-Scale Intelligence Quotient (FSIQ) ranged from 95.5±13.5 (bicoronal) to 110.1±12.7(lambdoid), and there was no significant difference between the suture groups (p=0.12). The fiveindex scores, namely verbal comprehension, visuo-spatial construction, fluid reasoning, working
memory, and processing speed, were all within average ranges based on their age norms.
Conclusions : Minimally invasive strip craniectomy for craniosynostosis patients with various sutures
resulted in favorable five-year neurocognitive outcomes. Strip craniectomy might be an effective
surgical method in terms of the neurocognitive development of craniosynostosis patients.

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Oral presentation 7: CRANIOSYNOSTOSIS

A-0077
Transverse Sinus Dominance in Non-Syndromic Unilateral Coronal
Craniosynostosis
Vich YINDEEDEJ1, Noritsugu KUNIHIRO1, Ryoko UMABA1, Hiroaki SAKAMOTO1,
Kazuhiro YAMANAKA1, Tomohisa OKUMA2
1

Pediatric Neurosurgery, Osaka City General Hospital, Osaka, Japan,
Diagnostic Radiology, Osaka City General Hospital, Osaka, Japan

2

Introduction : In normal population, transverse sinus (TS) is predominantly on the right side,according to a work by Padget in 1950s and many works following. Padget hypothesized that thisright predominance might be related to the embryologic left innominate vein which was developed
and receive venous drainage later. In this study, the dominant TS tended to be found on the opposite
side of unilateral coronal craniosynostosis. This phenomenon does not appear in any reports to date.
Material & Methods : We searched for non-syndromic craniosynostosis cases from 1995 to August2023. We included patients who were diagnosed as 1.right unilateral coronal craniosynostosis(RCC) 2.left unilateral coronal craniosynostosis (LCC) 3.bilateral coronal craniosynostosis (BCC)
and 4.sagittal craniosynostosis (SC). We excluded cases with multiple suture craniosynostosis andposterior plagiocephaly cases. All intracranial venous sinuses were evaluated by MR venography
before surgery. TS dominance was classified into equal(E), right(R) and left(L).
Results : 77 cases were matched. Venous sinuses were evaluated at the mean age of 10.1 +/- 13.3
months. Difference of TS dominance was found statistically significant between both unilateral coronalcraniosynostosis (12 RCC = 1E-1R-10L, 13 LCC = 1E-9R-3L) compared with 16 BCC (2E-8R-6L), as
representative of bilateral lesions, and 36 SC (10E-16R-10L), as representative of midline lesion. We
found that 76% of unilateral coronal craniosynostosis cases had dominant TS in the opposite side to
the synostotic suture.
Conclusions : Higher ratio of TS dominance was found in the opposite side of synostotic
suture. These findings could motivate more studies in venous drainage pattern development of
craniosynostosis.

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A-0066
A case of atypical sagittal synostosis with prominent digital impressions,narrowing of the posterior cranial fossa, hydrocephalus, and posterior nasal
stenosis
Ayaka ICHISE6, Atsuko HARADA1, Toyo SHIMIZU1, Masami KURAMOTO6, Yoshinori KADONO6,
Kazushige MAENO6, Nayuta HIGA2, Tatshuki OYOSHI3, Akinori ASAKA4, Shigeo KYUTOKU5,
Kouichi UEDA4
1

Department Of Pediatric Neurosurgery, Takatsuki Hospital, Takatshuki-city, Japan, 2Department Of
Neurosurgery, Kagoshima University, Kagoshima-city, Japan, 3Department Of Neurosurgery, Neurosurgery
Center, Ichikino-city, Japan, 4Department Of Plastic And Reconstructive Surgery, Osaka Medical And
Pharmaceutical University, Takatshuki-city, Japan, 5Division Of Reconstructive Plastic Surgery, Nara City
Hospital, Nara-city, Japan, 6Department Of Neurosurgery, Takatsuki Hospital, Takatshuki-city, Japan

Introduction : Sagittal synostosis frequently manifests as an isolated anomaly. We present a caseof sagittal synostosis associated with prominent digital impressions, hypoplastic posterior fossa,
hydrocephalus, and posterior nasal stenosis.
Material & Methods : The patient was a 24-month-old boy who had been referred to a former hospitalat 5 months of age due to complaints of prominence of the forehead and unnatural steps on theparietal bone. Computed tomography (CT) revealed dolichocephaly (cephalic index 73), depressionof the parietal peak posterior to the coronal suture, notable digital impressions, and ventricularenlargement. Magnetic resonance imaging (MRI) disclosed hypoplastic posterior fossa. Severe
symptoms of nasal stiffness were due to posterior nasal stenosis.
Results : At 6 months of age, he underwent suturectomy followed by helmet therapy. A CT scan at
18 months of age revealed fusion of the bilateral coronal and lambdoid sutures, as well as increased
digital impressions. Subsequently, he underwent posterior vault distraction osteogenesis (PVDO) at
22 months of age. Prior to PVDO surgery, the Kyoto Scale of Psychological Development indicated adevelopmental quotient of 99 (Average: 100, Over 90: Normal), without signs of developmental delay.
Conclusions : We presented an atypical case of sagittal synostosis, potentially indicative of a certain
syndrome. The patient has grown up with no developmental delay noted to date, after undergoing
cranial and hydrocephalus surgeries at optimal timing. However, it is important to continue monitoring
cranial morphology as well as psychomotor development.

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A-0074Growth Curves for Intracranial Volume and Two-dimensional Parameters
for Japanese Children without Cranial Abnormality: Toward Treatment of
Craniosynostosis
Tomita YOUSUKE1, Masahiro KAMEDA2, Date ISAO1
1

Neurosurgery, Okayama Rousai Hospital, Okayama, Japan,
Neurosurgery, Osaka Medical And Pharmaceutical University, Osaka, Japan

2

Introduction : In the management of patients with craniosynostosis, it is important to understandgrowth curve of the normal cranium. Although 3D CT images taken in thin slices are easily available
nowadays, data on the growth curves of intracranial volume (ICV), cranial length, cranial width, andcranial height in the normal cranium are mainly based on older studies using radiography, and there
are insufficient reports using CT images especially taken in thin slices. The purpose of this study is toestablish growth curves in the normal cranium of Japanese children using thin slice images.
Material & Methods : Cranial images of 106 subjects (57 males, 49 females, aged 0–83 months)
without significant cranial abnormalities were retrospectively analyzed. Using thin slice CT
images, the ICV and two-dimensional parameters such as cranial length, cranial width, and cranialheight were measured by iPlan®. Cephalic index (CI) and cranial vault asymmetry index (CVAI) werealso measured.
Results : The ICV growth curves for males and females were similar in shape. As with the ICV, thetwo-dimensional parameters increased most rapidly in the first year after birth. The mean CI was
88.3±5.7, and the mean CVAI was 3.8±3.2%. There was no significant difference in CI and CVAI
between the sexes or among any age groups.
Conclusions : These data will enable us to compare these specific measurements in craniosynostosis
patients directly with those of normal children, which will hopefully help in managing these patients.

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A-0091Treatment strategy for craniosynostosis at Okayama Craniofacial Center
Joji ISHIDA1, Takaya SENOO2, Yasuki SURUGA1, Yuki EBISUDANI1, Tomita YOUSUKE3,
Yoshihiro KIMATA2, Takao YASUHARA1, Isao DATE1
1

Neurological Surgery, Okayama University Faculty Of Medicine, Dentistry, And Pharmaceutical Sciences,
Okayama, Japan, 2Plastic And Reconstructive Surgery, Okayama University Faculty Of Medicine, Dentistry,
And Pharmaceutical Sciences, Okayama, Japan, 3Neurosurgery, Okayama Rosai Hospital, Okayama, Japan

Introduction : In the treatment of craniosynostosis, it is important to improve skull shape as wellas cranial volume expansion. We have established the Okayama Craniofacial Center (OCFC) to
determine the indications for craniosynostosis surgery and to perform surgery and postoperative
follow-up since 2009.
Material & Methods : We retrospectively reviewed 58 cases of craniosynostosis (17 syndromic, 41
non-syndromic) and 68 surgeries were performed at the OCFC over a decade from January 2014 toAugust 2023.
Results : Cranial morphology was quantitatively evaluated in midline sagittal and horizontal crosssections based on the standard Japanese pediatric range obtained from CT images to determine
the direction and amount of cranial displacement. A 3D full-scale plaster model of the skull was
prepared to plan the osteotomy line and extensor position, and a silicone template was provided for
intraoperative use. Surgical procedures included 35 cases of Multi-directional Cranial Distraction
Osteogenesis (MCDO), 13 cases of posterior cranial vault distraction, 4 cases of other distraction,
10 cases of suturectomy, and 6 cases of other one-stage cranioplasty procedures. All surgeries were
performed safely as preplanned. Minor complications were wound infection in 5 patients (5/68, 7.3%),
CSF leak in 4 patients (4/68, 5.9%), and damage of the distraction frame in 4 patients (4/52, 7.7%),
which required antimicrobial therapy, hospitalization, and removal of the distraction frame prior to thescheduled date.
Conclusions : Safe and precise cranioplasty have been provided as OCFC. We have dedicated toproviding optimal care through case review and technical refinement.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 7: CRANIOSYNOSTOSIS

A-0141
Factors to Avoid Blood Transfusion in Craniosynostosis Surgery
Yuki KIMOTO1, Atsuko HARADA2, Yumi DOI3, Shigeo KYUTOKU4, Koichi UEDA5
1

Department Of Neurosurgery, Osaka University Graduate School Of Medicine, Suita City, Osaka, Japan,
Department Of Pediatric Neurosurgery,, Takatsuki General Hospital, Takatsuki City, Osaka, Japan,
3
Pediatric Perioperative Center, Takatsuki General Hospital, Takatsuki City, Osaka, Japan,
4
Division Of Reconstructive Plastic Surgery, Nara City Hospital, Nara City, Nara, Japan,
5
Department Of Plastic Reconstructive Surgery, Osaka Medical And Pharmaceutical University, Takatsuki
City, Osaka, Japan
2

Introduction : Craniosynostosis surgery often requires intraoperative and postoperative bloodtransfusions. We will discuss the factors that prevent blood transfusion in the perioperative period.
Material & Methods : From December 2013 to March 2023, we have encountered 128 patients
who underwent craniosynostosis surgery at our hospital and investigated the factors might cause
intraoperative and postoperative blood transfusions.
Results : Of the 128 patients, 103 underwent cranioplasty, and 25 underwent endoscopic
suturectomy. Hemodilutional autologous blood transfusion or blood salvage autotransfusion devices
were used in 87/88 patients (body weight ≧ 10 kg), and endoscopic surgery was performed in 25/30
patients (age < 7 months). Additionally, after April 2017, 92/113 patients supplied iron (mean 2.6 mg/kg) for a mean of four weeks before surgery. Hemoglobin levels at the start of surgery tended to behigher in the iron administered group than in the non-iron group (11.3 g/dl vs. 10.8 g/dl, p-value =0.0565). Transfusion rate was 22.7% (29/128). Concerning the factors leading to blood transfusion,weight at the time of surgery, sex, operative duration, amount of blood loss per weight, use ofendoscope, hemoglobin level at the start of surgery, and iron administration were analyzed using
logistic regression analysis. Weight and blood loss were found to be significant factors (p-values of
0.0015 and 0.00006, respectively). The receiver operating characteristic curve indicated that thethreshold for avoiding transfusion was a body weight of 12.8 kg and a blood loss of 8.3 ml/kg.
Conclusions : Body weight and blood loss during surgery were important factors in avoiding bloodtransfusion.

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A-0191
Navigation guided accurate osteotomy and preoperative simulation for
craniosynostosis with 3D-printed skull models.
Yosuke MIYAIRI1, Akihiro CHIBA1, Hiroaki SHIGETA1
1

Neurosurgery, Nagano Children’s Hospital, Azumino, Japan

Introduction : Craniosynostosis is a complex pathology involving orbital and facial bones together
with cranial deformity, and surgical treatment requires an accurate osteotomy for best functional andcosmetic results. 3D-printed skull models (3DPSM) are adopted for surgical training and preoperative
surgical planning, which improve the safety of the procedure. However, the conventional use of
3DPSM is separated from the improvement of the real-time intraoperative accurate osteotomy. Herein,
we present a novel navigation guided osteotomy using 3DPSM that can improve the quality of the
management of craniosynostosis.
Material & Methods : From April 2021 to August 2023, 19 consecutive patients including 4 metopic,
6 sagittal, 5 bicoronal, 4 multiple suture synostosis underwent navigation guided osteotomy for
craniosynostosis. We retrospectively analyzed procedural outcome. The surgery was performed
using the following method. At first, a 3DPSM is created, and an osteotomy is planned on the 3DPSM.
Next, the 3DPSM is registered to the navigation system and the osteotomy line is planned on the
cranial model within the navigation system. During the surgery, the patient’s head is registered, andafter a skin incision is made, the accurate osteotomy is performed using navigation system.
Results : In all 19 cases, the preoperatively planned osteotomy line could be reproduced to patient’s
cranium within a short time and the osteotomy performed safely. In one case, intraoperative reregistration was required for using navigation system.
Conclusions : The navigation guided osteotomy with 3DPSM can duplicate the accurate osteotomy
as preoperative planning and improve the quality of management. Further investigations are required
to verify the usefulness, potential risk, and limitations.

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A-0008Use of Piezoelectric for osteotomy in craniosynostosis – A single centre
experience
Ankur PATNI1, Manas PANIGRAHI1, Hemanth KUMAR2
1

Neurosurgery, Krishna Institute Of Medical Sciences, Hyderabad, India,
Plastic Surgery, Krishna Institute Of Medical Sciences, Hyderabad, India

2

Introduction : Craniosynostosis is a congenital malformation resulting in various degree of cranialand craniofacial deformities due to premature closure of one or more cranial suture. Previously
osteotomy for deformity correction was performed using drill which resulted in excessive bone andblood loss resulting in need of developing newer modality, Piezoelectric to overcome this problem.
Material & Methods : Retrospectively data was collected for last 10 years of patient operated for
craniosynostosis at our center and divided into two groups based on equipment used for osteotomy
during surgery.
Results : Total of 16 patients were operated in last 10 years. In initial 10 patients (Group A) Medtronichigh speed drill was used and subsequently after 2021, Piezoelectric was used in 6 cases (Group B).
Average age at time of surgery in group A and B were 20.7 and 13.5 months respectively. Average
duration of stay in hospital in group A and B were 7 and 8.83 days respectively. We had dural tear in
2 patients of group A and none in group B. Blood andbone loss was much less in group B patients.
Conclusions : Piezoelectric is a new advancement in field of osteotomy in craniosynostosis that canbe used for performing bone cutting with precision with minimal bone loss and avoiding dural tear.

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A-0046
Helmet therapy with Aimet: From the standpoint of also being involved in the
StarbandMasahiro KAMEDA1, Hironori YAMADA1, Masahiko WANIBUCHI1
1

Department Of Neurosurgery, Osaka Medical And Pharmaceutical University, Takatsuki, Osaka, Japan

Introduction : Starband® and Aimet® are representative helmets used in Japan for helmet therapy
for cranial deformity. We recently started helmet therapy with Aimet®. However, the criteria for
determining the efficacy of the two helmets are not completely the same. We report the results oftreatment using the cranial vault asymmetry index (CVAI) and the cephalic ratio obtained from bothhelmets.
Material & Methods : Sixty-one Starband® cases (46 with plagiocephaly and 15 with brachycephaly)and 14 Aimet® cases (9 with plagiocephaly and 5 with brachycephaly) treated were included in the
study. In addition to the timing and duration of helmet wear, the degree of deformity and the degree of
improvement before and after treatment were studied and analyzed based on the Starband® severity
classification. Differences in the effect of treatment depending on the start of treatment were also
examined.
Results : In plagiocephaly, a significant difference in the degree of improvement was observed
between the Starband® group that started treatment by 6 months of age and the group that started
treatment after that age, but not in the Aimet® group. For brachycephaly, there was no significant
difference in the degree of improvement by time of treatment initiation. Aimet® was statistically noninferior to Starband® in the treatment of plagiocephaly and brachycephaly.
Conclusions : We initiated Aimet® treatment with the goal of achieving stable results with Starband®,but were able to initiate it with statistical non-inferiority, and since both helmets have advantages
over their counterparts, patient families can choose which helmet to use for treatment based on theirpreference.

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A-0070Long-term outcome of Cranioplasty using hydroxyapatite granules andabsorbable mesh plates for skull defects in children
Ryuichi HIRAYAMA1, Naoki KAGAWA1, Reina UTSUGI1, Noriyuki KIJIMA1, Yoshiko OKITA1,
Haruhiko KISHIMA1
1

Neurosurgery, Osaka University School Of Medicine, Suita, Osaka, Japan

Introduction : For skull defects in children, autogenous bone reconstruction may not provide
complete coverage of the defect. In addition, long-term implantation of titanium plates can lead toproblems such as granulation and plate intrusion into normal tissues. We report on a trial cranioplasty
using an absorbable plate and granular hydroxyapatite for cranial defects and its long-term results.
Material & Methods : Eight children with skull defects were included in the study. (cranium bifida
occulta: 4 cases, epidermoid cyst: 2 cases, sinus pericranii: 1 case, postoperative bone defect: 1case) The average follow-up period was 6 years and 2 months. Autogenous bone debris harvested
by slightly removing the margins of the bone defect was mixed with granular hydroxyapatite artificial
bone and formed into a plate using fibrin glue. This material was filled into the bone defect andcovered and fixed with an absorbable mesh plate.
Results : In all cases, good closure of the bone defect was achieved without any surgicalcomplications such as infection or stray tissue. In two cases, a tendency toward resorption of theartificial bone was observed at the edge of the defect repair area on imaging during the second
follow-up period, but there were no strength problems on palpation and no cases requiring revision
treatment.
Conclusions : Although the minimally invasive technique is superior in terms of minimizing thesurgical field, including the extent of skin incision, some bone resorption was observed in relatively
large bone defects over a long period of time after surgery, and further follow-up is necessary.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 8: HYDROCEPHALUS 1

A-0010
The analysis of cerebrospinal flow dynamics in mouse fetuses - Cerebrospinal
fluid may flow out from the brain through the frontal skull base and choroid
plexusTakuya AKAI1, Toshihisa HATTA2, Hiromi SAKATA-HAGA2, Seiji YAMAMOTO3,
Shusuke YAMAMOTO1, Satoshi KURODA1
1

Neurosurgery, Toyama University, Toyama, Toyama, Japan,
Anatomy, Kanazawa Medical University, Uchinada, Ishikawa, Japan,
3
Pathology, Toyama University, Toyama, Toyama, Japan
2

Introduction : Cerebrospinal fluid (CSF) has been believed to be produced in choroid plexus, anddrain into sagittal sinus through arachnoid granules in one-way. Recently, new CSF drainage tracts
were proposed such as brain capillaries, meningeal and nasal lymphatic system. In this study, weinvestigated the extracranial outflow of particles in CSF. This analysis will contribute for the treatmentof hydrocephalus.
Material & Methods : Mouse fetuses at a gestational age of 13 days were used. Either Fluorescent
proves with differing molecular weights (MW) or gold particles with different size or fluorescentlabeled cadaverine were injected into the lateral ventricle. The probes movements were monitoredin live. Gold particles deposition was studied under stereomicroscope or electron microscope (EM).
Cadaverine deposition were observed under fluorescent microscope.
Results : 1) Fluorescent study: With an injection of low and high molecular weight (LMW, HMW)
probes conjugate, both probes dispersed into the brain, but only the LMW probe dispersed into thewhole body. The gate size to go out from brain is suspected as less than 1400. 2) Gold particle study:
The gold particles accumulated at the frontal skull base. EM study revealed gold particles deposition
between the ependymal cells. And only small size particle (2 nm) was found in liver. 3) Cadaverine
study: Its deposition was observed on the frontal skull base, choroid plexus, ependyma and perivascular space.
Conclusions : The particles in CSF may drain to extracranial space via frontal skull base and choroid
plexus through ependyma and peri-vascular space. This particles outflow is regulated by its MW and
size.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 8: HYDROCEPHALUS 1

A-0126
Family-base rare variant association analysis in Saudi Arabian hydrocephalus
subjects using whole exome sequencing
Ahmed AMMAR1, Dalal K BUBSHAIT2, Abdulrazaq ALOJAN1, Shuroq A ALSHARI1,
Cyril CYRUS3, Rawan ALANAZI1, Mohammed A AL GHAMDI2, Brendan J KEATING4,
Abdulrahman AL-ANAZI1, Noorah H AL QAHTANI5, Amein K AL-ALI3
1

Department Of Neurosurgery, Imam Abdulrahman Bin Faisal University, King Fahd Hospital Of The
University, Dammam, Saudi Arabia, 2Department Of Pediatric, Imam Abdulrahman Bin Faisal University,
King Fahd Hospital Of The University, Dammam, Saudi Arabia, 3Department Of Clinical Biochemistry,
Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia, 4Department Of Surgery, University Of
Pennsylvania School Of Medicine, Philadelphia, United States, 5Department Of Obstetrics And Gynecology,
Imam Abdulrahman Bin Faisal University, King Fahd Hospital Of The University, Dammam, Saudi Arabia

Introduction : Hydrocephalus is a highly heterogeneous multifactorial disease that arises fromgenetic and environmental factors. Familial genetic studies of hydrocephalus have elucidated fourrobustly associated hydrocephalus associated loci. This study aims to identify potential genetic
causation in cases of hydrocephalus, with or without spina bifida and Dandy Walker Syndrome (DWS),
using family-based rare variant association analysis of whole exome sequencing.
Material & Methods : We performed whole exome sequencing in 143 individuals across 48 families
where at least one offspring was affected with hydrocephalus (N.=27), with hydrocephalus with spina
bifida (N.=21) and with DWS (N.=3), using Illumina HiSeq 2500 instrument.
Results : No pathogenic or putative pathogenic single-nucleotide variants were evident in the four
known hydrocephalus loci in our subjects. However, after examining 73 known hydrocephalus genes
previously identified from literature, we identified three potentially impactful variants from the cohort.
Using a gene panel comprising variants in known neural tube defects loci, we identified a total of1024 potentially deleterious variants, of which 797 were missense variants and 191 were frameshift
variants, 36 were stop gain/loss variants. A small portion of our family pedigree analyses yielded
putative genetic signals which may be responsible for hydrocephaly elated phenotypes, however
the low diagnostic yield may be due to lack of capture of genetic variants in the exonic regions i.e.
structural variants may only be evident from whole genome sequencing.
Conclusions : We identified three potentially impactful variants from our cohort in 73 knownhydrocephalus genes previously identified in literature.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 8: HYDROCEPHALUS 1

A-0022
Normal Growth Curve of Choroid Plexus in Children: Implications for Assessing
Hydrocephalus and Choroid Plexus Hyperplasia
Hiroaki HASHIMOTO1, Osamu TAKEMOTO1, Yasuyoshi CHIBA1
1

Neurosurgery, Osaka Women’s And Children’s Hospital, Izumi, Japan

Introduction : Pediatric hydrocephalus assessment requires consideration of intracranial structure
growth, yet data on choroid plexus growth in children is limited. This study aimed to establish normal
growth curves for choroid plexus volume, and lateral ventricles volume. Additionally, we assessedhydrocephalus caused by choroid plexus hyperplasia (CPH).
Material & Methods : Head computed tomography (CT) scans of pediatric patients with minor headtrauma from Osaka Women’s and Children’s Hospital between March 2006 and May 2023 wereretrospectively analyzed. Intracranial volume, choroid plexus, and lateral ventricles volume were
calculated. Growth curves were constructed using sequential mean values.
Results : A total of 229 CT scans (94 from females) were analyzed, revealing positive correlations
among intracranial volume, choroid plexus volume, and lateral ventricles volume. Intracranial volume
showed rapid growth until around 20 months of age, while choroid plexus and lateral ventricles
volume increased rapidly at approximately one year of age, reaching plateaus at 1.5 mL and 10 mL,
respectively. Among three patients with CPH, abnormal volumes of choroid plexus (ranging fromz-normalized values of 24.11 to 51.17) and lateral ventricles (ranging from z-normalized values of
46.78 to 122.36) were observed. Two patients showed improvements in z-normalized intracranial
and lateral ventricles volumes following surgical interventions. In one patient, choroid plexus
volume reduced by approximately 24% (from z-normalized values of 51.17 to 38.93) after bilateralendoscopic plexus coagulation.
Conclusions : This study establishes normal growth curves for choroid plexus volume, and lateral
ventricles volume. These reference values enable objective assessment of abnormal values related tohydrocephalus and choroid plexus diseases, including CPH.

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4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 8: HYDROCEPHALUS 1

A-0016A Demographic Study and Success Rate of ETV + CPC in RSUP HAM Medan: A
5-Year Clinical Experience
Abdurrahman Mousa ARSYAD1
1

Neurosurgery, Universitas Sumatera Utara, Medan, Indonesia

Introduction : Hydrocephalus is the symptomatic accumulation of cerebrospinal fluid (CSF) inside
the cerebral ventricles. However, VPS is prone to frequent failures from mechanical obstructions,which require urgent shunt revision surgery. Innovated the treatment of infant hydrocephalus bydeveloping the ETV/CPC procedure. The main objective of this study was to describe the successrate of Endoscopic Third Ventriculostomy (ETV) Choroid Plexus Cauterization (CPC) H. Adam Malik
General Hospital Medan in 5 years of clinical experience.
Material & Methods : A retrospective study was undertaken at the H. Adam Malik General Hospital
Medan between January 2018 and December 2022. All records for pediatric patients who underwent
ETV and choroid plexus cauterization (CPC) at our center were included in the study. During thestudy, 23 cases of hydrocephalus were reviewed who were treated with ETV and CPC
Results : The success of ETV in treating hydrocephalus appears to be influenced by factors such as
the underlying etiology of hydrocephalus and the age of the patient. ETV shows lower success rates
in infants, particularly those younger than 1 year, compared to older children and adults. ETV remains
the preferred method, even for patients who have undergone shunt surgery in the past. The successof ETV may vary depending on different factors such as the ETVSS threshold, the underlying cause ofhydrocephalus, and the presence of shunt malfunction
Conclusions : These findings highlight the significance of age, etiology, and prior shunt usage
history as influential factors in the success or failure of ETV+CPC procedures72

4th Congress of Asian-Australasian Society for Pediatric Neurosurgery (AASPN2023)

Oral presentation 8: HYDROCEPHALUS 1

A-0019
Utility of Stented ETV (SETV)
Kazuhisa YOSHIFUJI1, Masayasu ARIHARA1, Nobuhiro MIKUNI2
1

Pediatric Neurosurgery, Hokkaido Medical Center For Child Health And Rehabilitation, Sapporo, Japan,
Neurosurgery, Sapporo Medical University, Sapporo, Japan

2

Introduction : ETV is a well-established surgical procedure for obstructive hydrocephalus, but it has
risks of stoma closure and obstructive scarring of the basal cistern. To enhance the patency of ETV,
we employed stented ETV (SETV) under certain conditions.
Material & Methods : A total of 10 patients who underwent SETV at the age of 3 months to 11 years(median 2 years) from 2010 to 2021 were retrospectively analyzed. Observational periods, durationsof using stent, were 6 days to 9 years.
Results : SETVs were conducted as second surgeries after the failure of prior standard ETV in 8
patients. In 2 patients whose tumor or hematoma immediately made ETV stomas blocked during
primary ETV, SETVs were adopted as first surgeries. Pathogeneses of ETV failure observed in 8
patients were regrowths of the third ventricle floor in 4 patients, adhesive obstructions of the basal
cistern in 2 patients, and blockages of stoma by recurred cyst in 2 patients. During the survey
periods, 6 stents were removed due to cures of hydrocephalus in 2 patients, switchings to VP shuntin 3 patients, or patient’s death in 1 patient. The other 4 stents have been effectively working for 6 to
9 years. No stent caused occlusion, difficulty in removal, and infection.
Conclusions : To avoid using foreign materials, standard ETV should take priority over SETV. SETV
makes CSF pathway more sustainable, however, and can be an option for salvage surgery after ETV
failure. If tumors or hematomas are about to occlude ETV stoma during surgery, SETV can become afirst-line surgery.

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A-0073
Endoscopic treatment for complications related to CSF shunt
Kenichi NISHIYAMA1
1

Neurosurgery, Niigata Medical Center, Niigata, Japan

Introduction : To clarify the management strategy and surgical technique with endoscope forcomplications related to CSF shunt.
Material & Methods : Complications of CSF shunt were roughly classified into four types as follows;
Obstruction, over-drainage, infections, Rostral MB syndrome. Endoscopic operations for those fourtypes were reviewed retrospectively. Indications, goals of operation and some special techniques are
discussed following the review.
Results : Diversion of CSF pathway with endoscope was a major procedure for functional impairmentof CSF shunt, which causes simple-complex hydrocephalus, such as unilateral hydrocephalus or
isolated fourth ventricle. This procedure works not only as bypass, but also as buffer for pulsatilepressure in the ventricles. To replace a simple shunt is considered standard goal. But some patientswith communicated hydrocephalus including slit-ventricle syndrome were successfully converted
into shunt-independent state. ETV was effective for Parkinsonism and mutism i.e. rostral midbrain
syndrome following CSF shunt, since repeated attacks of ventricular dilation and relaxation bychanging shunt pressure setting makes damages of MB reticular formation. Endoscopic CSF lavage
was indicated as an initial treatment for ventriculitis in some cases. In addition, endoscopic choroid
plexus cauterization makes time for delay in shunt replacement and was indicated in infectious
complications.
Conclusions : Endoscopic procedures should be considered in the first place for treatment of shuntrelated complications. The main objective is re-setting of a simple CSF shunt, however, convert into
shunt-independency with resolution of symptoms might be possible in certain cases.

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Oral presentation 8: HYDROCEPHALUS 1

A-0132
Endoscopic Third Ventriculostomy Success Rate in Younger Than 1 Year Old
Hydrocephalus Patients: A Meta-Analysis.
Abdulrazaq ALOJAN1, Sarah ALSAMIN1
1

Department Of Neurosurgery, Imam Abdulrahman Bin Faisal University, King Fahad Hospital Of University,
AlKhobar, Saudi Arabia

Introduction : In the last 2 decades, Endoscopic Third Ventriculostomy (EVT) is getting more popularin treating hydrocephalus cases as it helps in reducing the lifelong shunt insertion complications andit shows promising results. However, its success rate still not well established especially in infants(younger than 1 year old). In this meta-analysis, we sought to calculate the cumulative success rateof ETV in infants.
Material & Methods : Systemic Ovid MEDLINE and Cochrane Central Register of Controlled Trials
databases searches were conducted in 2023 by specific keywords, and without time limitation.
Inclusion criteria was: (1) ETV procedures were conducted on hydrocephalus cases. (2) Patientsage less than 1 year. (3) Success rate was calculated and documented. (4) Study design was
retrospective or retrospective cohort, or randomized clinical trial.
Results : 763 articles were found, after applying the inclusion criteria, only 11 were recorded andanalyzed using SPSS. 935 patients underwent ETV procedure, 338 (36%) of them underwent ETV withchoroid plexus cauterization (CPC). The weighted mean for success rates for ETV and ETV with CPC
were more than 52.14% (SD= 10.81) and 66.2% (SD= 2.33), respectively, after 6 months follow up.
Conclusions : ETV with and without CPC in hydrocephalus patients younger than 1 year were rarely
reported even though it could help in reducing shunt consequences from a young age. More than
50% of ETV cases were successful giving 1 between every 2 infants with hydrocephalus who require
treatment the chance of living shunt free.

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Oral presentation 8: HYDROCEPHALUS 1

A-0192
Assessing the Efficacy of Endoscopic Third Ventriculostomy with Choroid
Plexus Cauterization (ETV/CPC) in Pediatric Hydrocephalus: A Comprehensive
Study from South of Vietnam
LE QUANG MY1, PHAM MINH THANH1, NGO NGOC HA1, TO THI KIM THOA1
1

Pediatric Neurosurgery Dept, Children Hospital 2 (Bệnh Viện Nhi Đồng 2), Ho Chi Minh, Vietnam

Introduction : Pediatric hydrocephalus presents a significant challenge in neurosurgery, impacting
children’s health worldwide. We aimed to assess endoscopic third ventriculostomy (ETV) efficacy, withand without choroid plexus cauterization (CPC), in pediatric hydrocephalus management. Our study,
the largest in South Vietnam, includes diverse etiologies and an extended follow-up.
Material & Methods : A key distinguishing feature of this study lies in its all-inclusive inclusion criteria,
which encompassed all pediatric hydrocephalus patients treated with ETV/CPC and meticulously
tracked through the Redcap database until the study’s conclusion. Statistical analysis was performed
using SPSS software, incorporating Fisher’s exact tests and chi-square tests.
Results : Initially, 149 patients participated; 50 were excluded (33 tumors, 17 lost). 49.5% weremale, mostly under 12 months (mean age 26 months). Common etiologies: Dandy Walker (30.3%),
arachnoid cysts (16.2%), post-infection (12.1%), post-hemorrhage (12.1%). ETV success varied(8.3%-93%). Mean follow-up: 1,282 days; complications in 6 cases (4.03%). Age and etiology
influenced outcomes.
Conclusions : ETV, with or without CPC, demonstrates effectiveness comparable to that reported innumerous international studies. Notably, our study unveils a novel finding: the presence of residual
hemosiderin staining in the ventricles predicts treatment failure. The retrospective nature of the study,
primarily reliant on Redcap, while characterized by regular follow-ups, inherently harbors limitations.
The absence of a specific scoring system for success evaluation based on neurocognitive indicesrepresents a noteworthy limitation. Furthermore, the absence of comparative analysis with alternativehydrocephalus treatment modalities, such as ventriculoperitoneal shunting, within the same timeframe
presents an opportunity for future research to provide a more comprehensive understanding ofpediatric hydrocephalus management.

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A-0110
Clinical Outcome of Endoscopic Procedure in Patients with Shunt Malfunction
Kyung Hyun KIM1, Youngbo SHIM1, Ji Yeoun LEE1, Ji Hoon PHI1, Eun Jung KOH1,
Seung-Ki KIM1
1

Neurosurgery, Seoul National University Hospital, Seoul, Korea, Republic of

Introduction : The goal of this study was to analyze the clinical outcomes of endoscopic thirdventriculostomy (ETV) and endoscopic septostomy when shunt malfunction occurs in a patient who
has previously undergone placement of a ventriculoperitoneal shunt.
Material & Methods : From 2001 to 2020 at Seoul National University Children’s Hospital, patients
who underwent ETV or endoscopic septostomy for shunt malfunction were retrospectively analyzed.
Initial diagnosis (etiology of hydrocephalus), age at first shunt insertion, age at endoscopic
procedure, magnetic resonance or computed tomography image, subsequent shunting data, andfollow-up period were included.
Results : Thirty-six patients were included in this retrospective study. Twenty-nine patients, withshunt malfunction underwent ETV. At the time of shunting, the age ranged from 1 day to 15.4 years(mean, 2.4 years). The mean age at the time of ETV was 13.1 years (range, 0.7 to 29.6 years).
Nineteen patients remained shunt revision free. The 5-year shunt revisionfree survival rate was 69%(95% confidence interval [CI], 0.54-0.88). Seven patients, three males and four females, with shunt
malfunction underwent endoscopic septostomy. At the time of shunting, the age ranged from 0.2
to 12 years (mean, 3.9 years). The mean age at the time of endoscopic septostomy was 11.9 years(range, 0.5 to 29.5 years). Four patients remained free of shunt revision or addition. The 5-year shuntrevision-free survival rate was 57% (95% CI, 0.3-1.0). There were no complications associated withthe endoscopic procedures.
Conclusions : The results of our study demonstrate that ETV or endoscopic septostomy can beeffective and safe in patients with shunt malfunction.

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A-0158Long-term outcome of pediatric ventriculoperitoneal shunt surgery: a singlecenter study
Ryoko UMABA1, Noritsugu KUNIHIRO1, Hiroaki SAKAMOTO1, Kazuhiro YAMANAKA1
1

Pediatric Neurosurgery, Osaka City General Hospital, Osaka, Japan

Introduction : We assessed a single-center long-term outcome of ventriculoperitoneal shunt surgery
in pediatric patients.
Material & Methods : We reviewed patients aged 15 years and younger who underwent initial
ventriculoperitoneal shunt in our hospital between 1994 and 2007, under follow-up for more than 15
years.
Results : 199 procedures performed on 131 patients. Patients ranged from 0 day and 5 years
old (mean 8.5 months old). The follow-up period ranged from 15 to 27 years (median 18 years).
100 of first implanted valves were nonprogrammable and 31 were programmable. The causes ofhydrocephalus were myelomeningocele (32.8%), intraventricular hemorrhage (22.9%), congenitalhydrocephalus (19.8%), meningitis (5.3%) and other (19%). The causes of shunt revision were 130
shunt dysfunction, 14 infection, 4 other, and 51 shunt extension due to growth. Excluding planned
revisions for extension, the shunt survival rate at 1 year after shunt insertion was 67.2%, 54.2% at 5
years, 42.7% at 10 years and 40.5% at 15 years. The shunt survival rate at 1 year post-operatively
was 58.6% in patients first operated on within 3 months of age, and 84.1% after 4 months of age,a significant difference between the two. The shunt survival rate of programmable valves was
significantly higher than nonprogrammable valves.
Conclusions : Revisions after ventriculoperitoneal shunt in children tended to be performed in
the first year post-operatively. If planned extension was not taken into account, shunt survival rate
reached a plateau after approximately eight years post-operatively. Shunt implantation within 3months of the month was associated with a higher risk of shunt revision.

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A-0006
Outcomes comparing Ultrasound-guided VP shunt placement and Freehand
insertion
Shi Hui ONG1, Audrey TAN2, Leanne TAN2, Nivedh DINESH2, Kejia TEO2, Tseng Tsai YEO2,
Vincent NGA2
1

Medicine, Yong Loo Lin School Of Medicine, Singapore, Singapore,
Neurosurgery, National University Hospital Singapore, Singapore, Singapore

2Introduction : Ventriculoperitoneal shunt (VPS) insertion is a routine neurosurgical procedure done
to manage hydrocephalus. The final position of the shunt is crucial for shunt viability and durability.
Insertion can be conducted either by solely using anatomical landmarks (“freehand”) or under image
guidance. In this study, we retrospectively evaluated the accuracy and shunt revision rates between
US-guided placement and freehand insertion. Our secondary aim was to explore the learning curveof surgeons adopting US-guided VPS insertion.
Material & Methods : This study included patients who underwent VPS placement over the period ofJanuary 2018 to December 2021 at a single-center tertiary hospital. Both adult and pediatric patientswere recruited into the study. Accuracy of shunt placement was determined by evaluating the locationof the shunt catheter tip in the first post-operative imaging and the shunt revision rate. Shunts revised
within 30 days were presumed to be likely attributed to suboptimal VPS placement. Data analysis was
performed using RStudio.
Results : Rates of optimally placed and functioning shunts were higher under US guidance (79.5%
vs 50.6%) compared to freehand insertion (p <0.01). Rates of shunt revision within 30 days were
statistically lower in US-guided VPS insertion (5.7% vs 0.0%) compared to freehand even after
propensity-matched analysis (p = 0.02). There was no statistical difference in accuracy between
shunts placed by consultants and residents in the US cohort (p = 0.71).
Conclusions : Our findings support the advantages of adopting US-guided ventricular catheter
insertion. The learning curve for surgeons to adopt US guidance in VPS insertion is likely less steep
than imagined.

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A-0024
Risk factors for slit ventricle in the hydrocephalus children treated withventriculo-peritoneal shunt
Sadahiro NOMURA1, Natsumi FUJII1, Hideyuki ISHIHARA1
1

Neurosurgery, Yamaguchi University School Of Medicine, Ube, Japan

Introduction : The study analyzes the reasons for slit ventricle (SV) related ventriculo-peritoneal (VP)
shunt failure in pediatric patients with hydrocephalus.
Material & Methods : The study included 98 patients treated from 1991 – 2022. The VP shunts
were revised due to SV syndrome or SV related catheter obstruction in 19 patients (SV group). The
shunts functioned until the final follow-up day in 39 patients (Control group). The patients with shunt
malfunction not related to SV (n = 40) were excluded. Age at surgery, communication in CSF pathway,
brain atrophy, pressure setting of the shunt valve, and implantation of an anti-siphon device werecompared between the groups.
Results : The age at surgery in the SV group was 0.7 ± 1.1 years which was significantly younger
than that in the Control group at 2.3 ± 3.9 years (p < 0.05). The absence of brain atrophy was 94.7%
in SV and 51.3% in the Control groups (p < 0.01). None of the non-communicating hydrocephalus,
low-pressure valve, or no use of anti-siphon device significantly affected the shunt malfunction.
Among the 19 patients in SV group, 3 patients developed free from shunt due to compensation. The
other 16 patients received shunt revision with anti-siphon devices, and no shunt malfunction recurredfor 12.8 ± 7.6 years.
Conclusions : Shunts implanted in infancy and in no atrophic brain were the risk factors for SV
related shunt malfunction. Type of hydrocephalus and shunt system did not significantly influence
shunt malfunction. Anti-siphon device did not prevent SV; however, it did prevent recurrence of SV
related shunt malfunction.

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A-0002Pressure volume index withdrawal could be express by linear curve and it also
has a significant prognostic value.
Do-Sungs YOO1, Hae-Kwan PARK1
1

Neurosurgery, The Eunpyeong St Mary’s Hospital,the Catholic University Of Korea, College Ofmedicine.,
Seoul, Korea, Republic of

Introduction : Intracranial pressure (ICP) may be the most commonly applied neurophysiologic
monitoring and correlated well with clinical outcomes of the neurosurgical patient. In this study,
authors studied weather pressure volume index withdrawal (PVIw) could be expressed by linear
curve. And weather this PVIw value is significant as an additional prognostic factor, in patients withsimilar initial ICP and GCS.
Material & Methods : 171 patients, their PVIw curve was valid in linier curve (R2³0.95) were includedin this analysis. Authors defined PVIw3, as initial ICP minus ICP at 3 cc CSF withdrawal then divided
3. Analyze the correlation between the linear curve and exponential curve of PVIw. And also, analyze
the correlation between the patient clinical outcome and initial ICP, PVIw3, and both initial ICP plus
PVIw3.
Results : Brain compliance could be expressed by linear curve as well as exponential curve(correlation valid in 165/171 cases, p=0.047). And the correlation between the clinical outcome andthese two types of curves was (p=0.061 in exponential curve and p=0.022 in liner curve). The clinicaloutcome (linear regression, R2 value) was 0.076 in initial ICP, 0.073 in PVIw3 and 0.093 in both
initial ICP and PVIw3. On c2 analysis, PVIw3 values above 3, shows significant favorable outcome(p=0.017).
Conclusions : From this study, the ventricular pressure changes according to the CSF withdrawal
could be expressed by linear curve. Initial ICP plus PVIw3, shows more significant prognostic value
than initial ICP only.

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A-0044
Volume of cerebrospinal fluid removal by ventricular reservoir tapping forposthemorrhagic hydrocephalus in very low birth weight infants.
Masayasu ARIHARA1, Kazuhisa YOSHIFUJI1, Nobuhiro MIKUNI1
1

Neurosurgery, Hokkaido Medical Center For Child Health And Rehabilitation, Sappro, Japan,
Neurosurgery, Sapporo Medical University, Sappro, Japan

2

Introduction : For controlling intracranial pressure in preterm infants with posthemorrhagic https://www.google.co.jp/hydrocephalus (PHH), intermittent removal of cerebrospinal fluid (CSF) is widely
utilized. However, consensus on the optimal CSF removal volume remains elusive. We retrospectively
investigated the actual volume of CSF removal for PHH in very-low-birth-weight (VLBW) infants.
Material & Methods : This study included VLBW infants who underwent perioperative management
between 2011 and 2022. The study endpoint was either the time of ventriculoperitoneal shunt(VPS) placement or the cessation of CSF removal. Patients were categorized into two groups: thoseundergoing VPS and those avoiding it. CSF removal was quantified as a/bc ml/kg/day (a: total
CSF removal, b: the mean weight at reservoir placement and endpoint, c: the days from reservoir
placement to endpoint). Statistical analysis was carried out with Mann-Whitney U test.
Results : Fifteen patients, eleven with Grade 3 and four with Grade 4, were included. VPS was
performed in 10 patients and avoided in 5 patients. The removal volume was 10.5 ± 3.1 ml/kg/day(mean ± SD) in the VPS group and 5.2 ± 1.6 ml/kg/day in the group that avoided VPS, demonstratinga significant difference between the two groups (P < 0.05).
Conclusions : The mean daily removal volume in the VPS group closely approximated the previously
reported value of 10 ml/kg, while some cases required more removal. VPS may be avoided when thevolume of CSF removal is small. The removal volume should be considered in the individual case.

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A-0100Ventriculoperitoneal (VP) Shunt-Associated Abdominal Pseudocysts: twocases successfully treated by long term antibiotics therapy with external CSF
drainage.
Yuri YAMAGIWA1, Shunsuke ICHI1
1

Neurosergery, Japan Red Cross Medical Center, Tokyo, Japan

Introduction : Ventriculo-peritoneal shunt (VPS) associated abdominal pseudocysts (APC) isrelatively rare complication. While bacterial infection is suspected to form APC, the mechanism is
not fully understood. Furthermore, there is no clear consensus as to treatment strategy. We report
two cases of VPS-associated APC successfully treated with long-term intravenous antibiotics
administration (IA) along with external cerebrospinal fluid (eCSF) drainage.
M a te ri a l & M e t h o d s : C a s e 1 : A 1 9 - y e a r- o l d m a l e w i t h c o n g e n i t a l h y d ro c e p h a l u s
had severe abdominal distension due to a VPS-associated APC with negative CSF culture. The
shunt revision was performed after eCSF drainage for 18 days along with short term IA. However
the APC had recurred two weeks later, so we adopted much longer treatment i.e. for 6 weeks alongwith long term IA which enabled the sterile revision without recurrence. Case2 : A 9-year-old girlwho had underwent VPS surgery during infancy without history of shunt replacement. Her first shunt
malfunction occurred with APC. Even though CSF culture was negative, four week treatmentof thorough IA with eCSF drainage was chosen. Her APC had never recurred after VPS revision.
Results : Temporary eCSF drainage along with thorough broad spectrum IA for 4 ～ 6 weeks wasneeded to avoid the recurrence of APC. The P. acnes was detected in Case1,while no bacteria was
detected in Case2 throughout her clinical course.
Conclusions : No matter if the CSF culture is negative, we believe that the VPS replacement after
long term administration of broad spectrum antibiotics is effective for reducing the re-development of
APC.

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A-0106CT Studies on Disproportionally Dilated Lateral Ventricles in Infants with
Congenital Hydrocephalus in Bandung, Indonesia
Yulius HERMANTO1
1

Neurosurgery, Dr. Hasan Sadikin Hospital, Bandung, Indonesia

Introduction : Congenital hydrocephalus is caused by a complex interaction of genetic andenvironmental factors during fetal development. It is one of the most common congenital anomaliesof the central nervous system and is characterized by extensive accumulation of cerebrospinal
fluid within the ventricles of the brain due to an imbalance between synthesis and absorption of
cerebrospinal fluid. This study was planned to investigate disproportionally dilated lateral ventricles in
infants with congenital hydrocephalus.
Material & Methods : The dilatation of the lateral ventricle was analyzed based on CT scan or MRI
imaging from a total of 55 infants with congenital hydrocephalus that were hospitalized at a tertiary
hospital in Bandung, West Java, Indonesia from January 2022 – August 2023
Results : The majority of patients had posterior horn dilatation (n=25, 45.45%), followed by diffuse
dilatation of lateral ventricles (n=24, 43.63%), while anterior horn dilatation occurred in 6 out of
55 patients (n=10.91%). The most common associated pathology was holoprosencephaly (n=17,30.90%) and commonly observed in patients with dilatation of the posterior horn.
Conclusions : The posterior horn predominant type has a tendency to occur in congenital anomalies,
particularly in patients with holoprosencephaly, and diffuse type, particularly in patients with aquaductstenosis. This disproportional dilatation of the posterior horn suggests a vulnerability of periventricular
structure in the developing brain.

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A-0124
Problems in Management of Congenital Hydrocephalus in rural areas of GarutIndonesia: Three years working experience
Adhitya Rahadi YUDHADI2, Hadian ADHIPRATAMA1, Hasan BARAQBAH1, Farid YUDOYONO1,
Arief Setia HANDOKO1, Joses Terabunan ALVELA2, Novina Gestani YUSUF2
1
2

Neurosurgery, Neurospine And Pain Bandung, Bandung, Indonesia,
Neurosurgery, General Hospital Dr. Slamet Garut, Garut, Indonesia

Introduction : Congenital Hydrocephalus is a common health problem in the world. However, themain problem related to the congenital hydrocephalus in Indonesia is related to the absence of clear
epidemiological data; differences in socioeconomic levels, knowledge, attitudes and behavior of thelocal communities towards congenital hydrocephalus; and lack of access to the health insurance
systemMaterial & Methods : This study take place in neurosurgery’s outpatient clinic from January 2020
– January 2023 and the method is descriptive observational with mixed design, qualitative andquantitative, Respondents were 2 general practitioners, and 5 Neurosurgery’s outpatient clinic nurses
who were carried out by whole sampling, while for patient respondents it was conducted on 100
respondents by incidental sampling method. Univariate data analysis is presented in the form of
distribution tables for qualitative and theoretical analysis for qualitative.
Results : The results showed us that the parent(s)/guardian(s) had begun to understandhydrocephalus. However, there are still some obstacles that disrupt the education and management
process for patients with congenital hydrocephalus and will have a negative impact on patients andsociety in terms of health and resulted in the patient being brought to the hospital late. Apart from
that, lack of funds and difficulty in accessing health facilities make families reluctant to take patientsfor treatment.
Conclusions : TThere are still obstacles in management of congenital hydrocephalus like the lackof access for health insurance system, local culture and beliefs from local community that must bechanges to improve the treatment of congenital hydrocephalus in rurals area in Indonesia

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A-0131The Impact of Strict Shunt Protocol on Reducing the Infection Rate Following
Shunt Placement: A Prospective Cohort Study.
Abdulrazaq ALOJAN1, Ahmed AMMAR1, Haya EL HAJERI2, Frederic BOOP3,
Majed ALGHAMDI1, Sarah ALSAMIN1
1

Department Of Neurosurgery, Imam Abdulrahman Bin Faisal University, King Fahad Hospital Of University,
AlKhobar, Saudi Arabia, 2Nursing Department, King Fahad Hospital Of University, AlKhobar, Saudi Arabia,
3
Emeritus Chair, Department Of Neurosurgery, University Of Tennessee Health Sciences Center, MemphisMember, St. Jude Global Program Semmes- Murphey Clinic, Memphis Tennessee, United States

Introduction : Ventriculo-peritoneal shunt (VPS) is the treatment of choice in many hydrocephalus
cases. However, one of the common complications that increases its mortality and morbidity rate is
infection, as our center yielded 32% infection rate post-VPS in the literature. Thus, this paper aims todevelop new shunt protocol to reduce the infection rate post-VPS.
Material & Methods : Data from ninety-two controls was collected prospectively from hydrocephalus
patients who required VPS of a period of six-years (2017-2022), in Alkhobar, Saudi Arabia. The data
was categorized into pre and post Covid-19 pandemic cases, where those operated between 20172019 were considered as pre-pandemic cases.
Results : Ninety-two procedures for a total number of sixty-five cases were analyzed. The age
average was 141.4 months (SD=232.9), and 73.9% of the procedures were done on males. The
average compliance to the new protocol was 90.9%. Culture results were missed in 8 cases, andpositive in 4.8% only (4 cases) giving a ratio of 1 per 23 cases.
All infected patients were males, 75% were aging less than a month when operated, and they were
pre-Covid-19 cases. Twenty-eight elements of the new protocol were analyzed by Fisher’s Exact Test.
Multilayered wound closure with antibiotic was significantly associated with less infection rate (LR=7.5,
Fisher’s Exact Test p-value=.024). Other elements were statistically insignificant.
Conclusions : Development and following new shunt protocols could reduce infection rate especiallyin areas where they have high post-VPS infection rate. Although, one element was statisticallysignificant, other components were clinically or “financially” significant, particularly those which aretechnical, and must be considered.

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A-0146Preferences in the Diagnosis and Treatment of Pediatric Hydrocephalus among
Thai Neurosurgeons
Nunthasiri WITTAYANAKORN1, Ronnie BATICULON2, Sirachai PIYACHON1,
Lisa KITTISANGVARA1, Paveen TADADONTIP1
1
2

Surgery, Queen Sirikit National Institute Of Child Health, Bangkok, Thailand,
Neurosciences, Philippine General Hospital, University Of The Philippines, Manila, Philippines

Introduction : Hydrocephalus is one of the most commonly treated neurosurgical conditions inThailand. We aimed to describe the clinical experience and preferences of Thai neurosurgeons in the
diagnosis and treatment of pediatric hydrocephalus.
Material & Methods : We conducted an online survey using Google Forms among board-certified
neurosurgeons in Thailand from April 1 to May 31, 2023. The 48-item questionnaire collected dataon hydrocephalus etiology, surgical technique, shunt preferences, complications of treatment, andfollow-up practices.
Results : A total of 61 out of 538 registered neurosurgeons in Thailand completed the survey,
equivalent to an 11% response rate. The diagnosis of hydrocephalus is made using CT (93%)
and/or MRI (79%). The most common etiologies for hydrocephalus are post-hemorrhagic (57%)
and aqueductal stenosis (53%). Among all respondents, the preferred entry sites are frontal (53%)
and parietal (41%), and about 61% would use a differential-pressure valve as their first shunt. The
estimated rates of shunt infection, and overdrainage are 5% or less.
Conclusions : There is variability in the clinical practice of Thai neurosurgeons when treatinghydrocephalus in children. Long-term follow-up data are needed to determine whether thesedifferences have an impact on patient outcomes. The government should allocate additional
resources to manage patients with complex hydrocephalus and those with shunt-related
complications.

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A-0041
Ventriculoperitoneal Shunt Insertion as Primary Surgical Management for
Pediatric Idiopathic Intracranial Hypertension in Low- and Middle-Income
Countries: A Case Report and Review of Related Literature
John Emmanuel TORIO1, Kathleen KING1
1

Neurosurgery, University Of The East Ramon Magsaysay Memorial Medical Center, Inc., Quezon City,
Philippines

Introduction : Idiopathic intracranial hypertension is a condition of elevated intracranial pressurein the absence of clinical, laboratory or radiological evidence of an intracranial space occupying
lesion, which commonly affects women of reproductive age but can occur in the pediatric population.
Typical clinical manifestations change with age thus diagnosis could be late. Ventriculoperitoneal
shunt is one of the surgical options for medically resistant IIH but outcomes in the existing studies
and literatures among pediatric population were limited.
Material & Methods : Case Report
Results : We present a case of a 10 year-old male admitted in our institution for sudden blurring ofvision. Series of tests were done including Cranial MRI/MRA, CT venogram and immunoserology
revealed unremarkable results. Lumbar tap showed high opening and closing pressure with normal
CSF studies, fulfilling the Modified Dandy criteria for the diagnosis of IIH. He subsequently underwent
right parietal ventriculoperitoneal shunt insertion using neuronavigation. Post-operatively, improved
visual acuity and resolution of headaches were documented.
Conclusions : Ventriculoperitoneal shunt has become the procedure of choice for treatment of
idiopathic intracranial hypertension among other surgical interventions. The use of neuronavigation
has shown to achieve optimal placement of ventricular catheter when compared to conventional shunt
surgery. Significant improvements in headache, stabilization of vision and resolution of papilledema
have been reported. Given the limitations in setting such as here in the Philippines, it is therefore
prudent to prioritize this as surgical management of pediatric idiopathic intracranial hypertension.

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A-0114
TREATMENT OF PEDIATRIC SHUNT INFECTIONS IN INDONESIA: A SINGLECENTER EXPERIENCE
Muhammad Azhary LAZUARDY1, Mirna SOBANA2
1
2

Surgery, Sultan Imanuddin Hospital, Pangkalan Bun, Indonesia,
Neurosurgery, Hasan Sadikin Hospital, Bandung, Indonesia

Introduction : Shunt infection is a catastrophic complication of VP shunt insertion in children withhydrocephalus. The management is complex and requires a long time of hospitalization, resulting inincreased morbidity and mortality.
Material & Methods : An observational prospective study of pediatric patients (<18 years old) withshunt infections at Hasan Sadikin Hospital Bandung Indonesia was performed between March 2019and March 2020. The patients were treated according to the hospital’s shunt infection protocol, which
consists of shunt removal with EVD insertion, antimicrobial treatment administration, and 2 timesnegative cultures before putting on a new device. Patient outcomes were assessed by looking at themortality rate and Functional Status Scales (FSS).
Results : A total of 28 patients were included in this study. The median age was 5 months and mostof the patients were boys (60,7%). The median time interval between the first surgery to the onset of
infection was 10 weeks. Seventeen patients (60,7%) had shunt revision surgery before the infection.
The most isolated bacterial pathogens from the culture were Staphylococcus aureus (35,7%)
and Staphylococcus epidermidis (32,1%). The median length of hospital stay was 36.5 days. Seven(25%) of the patients died during the hospitalization. Based on cumulative FSS scores among
21 patients discharged at the end of the treatment, 12 had mild dysfunction, 6 had moderate
dysfunction, and 3 had normal functional status.
Conclusions : Shunt infection remains a cause of morbidity and mortality in children withhydrocephalus who underwent shunt surgery. A rigidly applied therapy protocol is important in thetreatment of shunt infection.

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A-0056
Diagnosis and Treatment of Cerebrospinal Fluid Leakage in Children
Masahiro JOKO1, Fumiaki SAITO1, Jun MUTO1, Tatsushi INOUE1, Yuichi HIROSE1
1

Neurosurgery, Fujita Health University School Of Medicine, Toyoake,Aichi, Japan

Introduction : Orthostatic headache associated with cerebrospinal fluid(CSF) leakage may occur asa result of sports injuries, traffic accidents, fall injuries, or sudden increases in abdominal pressure,and may be difficult to diagnose and treat.The purpose of this study is to present our institutional
experience in the diagnosis and treatment of CSF leakage in children.
Material & Methods : This is a retrospective study of the treatment of children 15 years old or
younger presenting with orthostatic headache associated with CSF leakage between April 2020 andAugust 2023.Orthostatic headache was evaluated with the Lumbar-uplift test (LUP test).Medication,
intravenous infusion, epidural saline infusion, and epidural blood patch were selected according tosymptoms.
Results : 9 patients were conducted. 2 patients were male and 7 were female.The median age ofpatients was 13.4 years (range 9 to 15 years).Causes of CSF leakage were sports injury in 4 cases,
traffic accident in 2 cases, fall injury in 1 case, and sudden increase in abdominal pressure in 2
cases.LUP test was positive in all patients. Radioisotope cisternography (RIC) was performed in one
patient.Medication alone was given to 1 patient, medication and intravenous infusion to 2, medicationand epidural saline infusion to 2, medication, intravenous infusion, and epidural saline infusion to 3,
and medication, intravenous infusion, epidural saline infusion, and epidural blood patch in 1 patient.
Orthostatic headache improved in all patients.
Conclusions : RIC and CT myelography require dural puncture, which is more invasive to the patient.
It may be useful to perform epidural saline infusion for diagnostic and therapeutic purposes.

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