Pediatric Neurosurgery

Peginterferon alfa-2a for cystic craniopharyngioma treatment

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Peginterferon alfa-2a for cystic craniopharyngioma treatment

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

Craniopharyngiomas, especially their cystic forms, pose unique management challenges due to their proximity to critical neurovascular structures. Intracystic therapies offer a minimally invasive alternative to repeated surgical interventions. Over the past decade, interferon-alfa-2a/2b emerged as a viable intracystic treatment due to its anti-proliferative and immune-modulating properties, coupled with low toxicity. However, discontinuation of commercial availability prompted the search for alternatives.

Hedrich et al. describes a retrospective case series, including five patients with intracystic peginterferon alfa-2a for cystic craniopharyngioma treatment according to an innovative care protocol. After initial CP cyst aspiration, peginterferon alfa-2a was injected once per week via an Ommaya reservoir for 6 weeks followed by response assessment with MRI.

Patients’ age ranged from 4 to 54 years (four patients <12 years, one adult patient). Intracystic therapy with peginterferon alfa-2a was tolerated well by all five individuals without any major toxicities and resulted in cyst shrinkage in all of the five patients. The importance of a permeability study prior to commencing intracystic therapy became apparent in one patient who suffered from cyst leakage.

Intracystic treatment with peginterferon alfa-2a was found to be a tolerable and efficacious treatment modality in patients with cystic craniopharyngioma. This experience warrants further research with a larger number of patients with measurement of long-term efficacy and safety outcomes 1).

The authors propose peginterferon alfa-2a, a pegylated form with extended half-life and established safety profile in other indications, as a substitute, presenting a retrospective case series evaluating its feasibility and safety.

Study Design and Methodology

– Design: Retrospective case series

– Sample: 5 patients (age 4–54; 4 children, 1 adult)

– Protocol: After initial cyst aspiration, peginterferon alfa-2a was administered weekly for 6 weeks via an Ommaya reservoir.

– Follow-up: MRI for response assessment

– Pre-treatment: Permeability study was highlighted as essential following one adverse case of leakage.

🔎 Strengths:

– Innovative use of peginterferon alfa-2a to fill a therapeutic gap.

– Uniform protocol across cases.

– Clear documentation of safety and early efficacy.

– Broad age range increases generalizability.

⚠️ Limitations:

– Very small sample size (n=5) limits statistical validity.

– Retrospective nature introduces potential bias and lacks standardized outcome metrics.

– Short-term follow-up; no data on recurrence, endocrine impact, or long-term survival.

– No comparator group (e.g., standard interferon alfa-2a or surgery-only) limits interpretation of relative efficacy.

Results

– Safety: No major toxicities reported in any patient.

– Efficacy: Cyst shrinkage achieved in all five patients.

– Complication: One patient experienced leakage, underscoring the need for a permeability test.

The data supports the hypothesis that peginterferon alfa-2a is a safe and potentially effective intracystic agent in this context.

Discussion and Clinical Relevance

This study provides preliminary real-world evidence that peginterferon alfa-2a can serve as an effective intracystic treatment option for cystic craniopharyngiomas, particularly important in the wake of discontinued access to interferon alfa-2a. The lack of significant toxicity is encouraging, especially in pediatric patients.

However, due to the small number of cases and lack of long-term outcome data, the findings should be interpreted as hypothesis-generating rather than practice-changing. Further research in prospective, multi-institutional trials with larger cohorts is warranted.

Conclusion Hedrich et al. offer a promising alternative approach for managing cystic craniopharyngiomas using peginterferon alfa-2a. The treatment appears feasible, safe, and effective in the short term. Yet, the study’s limitations — particularly its size and retrospective design — mean that broader validation is essential before widespread clinical adoption.

Comparative Analysis of Intracystic Treatments

Peginterferon alfa-2a vs Bleomycin vs Radioisotopes

Feature/Agent Peginterferon alfa-2a Bleomycin Radioisotopes (e.g., P-32, Y-90)
Mechanism of Action Immunomodulatory and antiproliferative Cytotoxic antibiotic causing DNA strand breaks Beta radiation causing localized cyst wall necrosis
Dosing Protocol Weekly x6 via Ommaya Multiple instillations (e.g., 4–6 doses over weeks) Single or repeated instillation; dosimetry-based
Age Use Pediatric and adult Caution in young children due to neurotoxicity Generally avoided in children <5–6 years old
Safety Profile Excellent short-term tolerability in small series Risk of chemical meningitis, neurotoxicity Risk of CSF leak, radiation necrosis, hypothalamic damage
Key Risks Cyst leakage (1 case in 5); minimal toxicity Seizures, necrosis if drug leaks to parenchyma Radiation exposure to critical adjacent structures
Regulatory Access Off-label, emerging use Widely available Often restricted, requires radiopharmacy services
Onset of Response Gradual shrinkage over weeks Moderate to rapid Rapid but with potential delayed adverse effects
Imaging Follow-up MRI after 6 weeks MRI at regular intervals Imaging + dosimetry (CT/SPECT) required
Long-Term Data Limited (new approach, case series only) Moderate, decades of use Available, esp. from Europe, but often in outdated protocols
Procedure Requirements Ommaya reservoir; permeability test recommended Ommaya reservoir or catheter Ommaya + radiation safety protocols

Summary Recommendations

Agent Advantages Disadvantages
Peginterferon alfa-2a Favorable safety, non-cytotoxic, off-label alternative to IFN-α2a Limited experience, unclear long-term outcomes
Bleomycin Effective and accessible; longer track record Neurotoxicity risk if leakage occurs; more systemic side effects
Radioisotopes Potent and often effective with fewer instillations Technically demanding; radiation risks; contraindicated in very young children

When to Consider Each Treatment?

* Peginterferon alfa-2a → Ideal for younger children or when minimal toxicity is essential. Requires close monitoring and permeability testing. * Bleomycin → Suitable where experience exists with its use. Effective but requires caution regarding leakage and systemic toxicity. * Radioisotopes → Best reserved for specialized centers with radiation safety protocols and older pediatric or adult patients with refractory cysts.

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🧠 Flowchart Logic

Is the patient under 5 years old?

→ Yes → ❌ Avoid radioisotopes

→ No → ✅ Radioisotopes may be considered

Is radiation facility & radiopharmacy available?

→ Yes → Consider radioisotopes

→ No → Proceed to next

Is cyst accessible with Ommaya and permeability confirmed?

→ No → ❌ Intracystic therapy not recommended

→ Yes → Proceed to next

Is neurotoxicity a major concern (e.g., very young child, hypothalamic proximity)?

→ Yes → ✅ Prefer Peginterferon alfa-2a

→ No → Proceed to next

Institutional experience with bleomycin?

→ Yes → Consider bleomycin

→ No → Consider peginterferon alfa-2a

1)

Hedrich C, Patel P, Haider L, Taylor T, Lau E, Hook R, Dorfer C, Roessler K, Stepien N, Lippolis MA, Schned H, Koeller C, Mayr L, Azizi AA, Peyrl A, Lopez BR, Lassaletta A, Bennett J, Gojo J, Bartels U. Feasibility, tolerability, and first experience of intracystic treatment with peginterferon alfa-2a in patients with cystic craniopharyngioma. Front Oncol. 2024 Jul 10;14:1401761. doi: 10.3389/fonc.2024.1401761. PMID: 39050573; PMCID: PMC11266088.

Racial disparities in hydrocephalus treatment

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Racial disparities in hydrocephalus treatment

Several studies of administrative data have noted higher mortality rates for Black/African American children with shunted hydrocephalus. A longitudinal study of children with hydrocephalus secondary to myelomeningocele showed lower lifetime rates of shunt revision in minority children compared to White children, indicating a possible disparity in hydrocephalus treatment. The goal of this study is to identify racial and ethnic disparities in mortality or shunt revision rates by using the Hydrocephalus Clinical Research Network (HCRN) hydrocephalus registry sample.

The HCRN registry was queried for patients with shunted hydrocephalus for whom data on all lifetime hydrocephalus procedures were available. Patients with a primary shunt placement before 2023 were included, with follow-up extending through March 19, 2024. A Cox proportional hazards model was created to determine the effect of race and ethnicity on mortality while controlling for age at initial shunt placement, sex, hydrocephalus etiology, gestational age at birth, and the presence of complex chronic conditions. Similarly, a proportional means model was used to evaluate the association with the lifetime number of shunt revision surgeries. The author hypothesized that when controlling for other variables, minority children would have higher mortality and fewer shunt revision surgeries than White children.

A total of 5656 children were included in the analysis of mortality. There were 579 deaths. Race and ethnicity were independently associated with mortality, with Black (HR 1.32, 95% CI 1.05-1.65), other non-White (HR 1.39, 95% CI 1.03-1.86), and Hispanic (HR 1.50, 95% CI 1.22-1.84) children having a higher mortality rate than White children. In the analysis of 4081 children with shunts, Hispanic ethnicity was also independently associated with fewer total shunt revisions (HR 0.84, 95% CI 0.72-0.98).

In children with hydrocephalus, when controlling for other factors, there is a higher mortality rate among Hispanic, Black, and other non-White children, and fewer shunt revisions among Hispanic children. These findings highlight important potential disparities in hydrocephalus treatment 1).

Patient race (i.e., White; Native Hawaiian, or other Pacific Islander) was found to be associated with iNPH development. Meanwhile, after excluding those with cerebrovascular disease, cardiovascular risk factors were not found associated with iNPH. Lastly, iNPH cases were more inclined to have a history of alcohol use disorder and prior psychiatric disorder. Overall, this data reveals that a racial disparity exists amongst iNPH, as well as highlights the role of various cardiovascular and psychiatric risk factors, which can potentially provide direction in etiology elucidation 2).

Among preterm infants with intraventricular hemorrhage and resultant PHH, black infants and those insured by Medicaid have significantly increased mortality but these 2 effects are independent. Further studies are needed to fully understand the factors affecting these racial and socioeconomic disparities 3).

Findings in a study, that utilized US population-level data, suggest the presence of racial and socioeconomic status outcome disparities following pediatric CSF shunting procedures 4).

A retrospective chart review was performed on all pediatric patients who underwent ventriculoperitoneal shunting from 1990-2010 at the Department of Neurological Surgery, University of Rochester Medical Center, 601 Elmwood Ave., Box 670, Rochester, NY, 14642, USA. Race and insurance type were recorded and assessed against specific outcome measures to statistically compare complication rates.

A complete record was found for 373 patients who received 849 shunting procedures at the institution. No differences were found between racial groups and insurance type for overall shunt survival, total revision number, or average time to failure. However, nonwhite patients spent an average of 3 days longer in the hospital at initial shunting (p = 0.04), and those with public insurance stayed for 5 days longer (p = 0.002). Patients with public insurance were more likely to present with shunt failure from outside hospitals (p = 0.005) and be born prematurely (p < 0.001). Private patients were more likely to have a neoplasm present at the time of initial shunt placement (p = 0.003).

While the overall revision rate was not affected by race or insurance status, there were significant delays in discharge for patients with public insurance. Moreover, potential disparities in outpatient access to primary physicians and specialists may be affecting care 5)

The literature examining racial and ethnic disparities in pediatric hydrocephalus reveals consistent evidence that minority populations, particularly Black, Hispanic, and other non-White children, experience worse outcomes compared to their White counterparts. The primary study by Rocque et al. (2025) using the Hydrocephalus Clinical Research Network (HCRN) registry strengthens the case for systemic inequities in healthcare delivery and outcomes.

1. Strengths of the Primary Study (Rocque et al., 2025)

Large, prospective dataset: With 5,656 children included in the mortality analysis and 4,081 in the shunt revision cohort, the study offers robust statistical power. Rigorous methodology: The use of Cox proportional hazards models and control for confounding variables (e.g., age at initial shunt, gestational age, chronic conditions) increases the reliability of the observed associations. Novel findings: The association of higher mortality in minority children and fewer revisions in Hispanic children, despite controlling for clinical variables, points to care process disparities rather than purely biological explanations.

2. Limitations and Interpretative Cautions

Causality remains unclear: The study is observational. While associations are strong, they do not establish causality. The lower revision rate among Hispanic children could either reflect undertreatment, barriers to access, or better surgical outcomes — though the higher mortality suggests the former. Socioeconomic data not directly integrated: While race and ethnicity are analyzed, insurance status, income level, and neighborhood-level SES indicators are not included. This limits insight into the complex interplay between race and class. Data source limitations: The HCRN centers may not be fully representative of all geographic or institutional contexts, potentially introducing bias. Synthesis with Supporting Literature The findings of Rocque et al. are echoed across several studies:

Jin et al. (2016) and Attenello et al. (2015) highlight that racial and economic disparities are independent predictors of increased mortality in hydrocephalus and related pathologies (e.g., PHH). Medicaid coverage — a proxy for low SES — independently correlates with worse outcomes, reinforcing the notion that both race and poverty are crucial risk factors.

Walker et al. (2014) found no differences in shunt survival or revision numbers, but nonwhite and publicly insured children had longer hospital stays and were more likely to present with complications from outside facilities, suggesting disparities in pre- and post-hospital care access, rather than in acute management.

Ghaffari-Rafi et al. (2020), while focused on iNPH, support that race (and potentially psychiatric comorbidities) may play a role in disease development and care patterns. Though not directly comparable to pediatric hydrocephalus, these data emphasize broader racialization of neurological care.

Key Themes and Implications

A. Structural and Institutional Bias These disparities may arise from implicit bias, differential access to care, differences in follow-up protocols, or parental engagement shaped by historical mistrust in healthcare institutions. Fewer shunt revisions in Hispanic children, despite higher mortality, may suggest under-recognition or under-treatment of shunt failures.

B. Socioeconomic Determinants

Insurance status, hospital of origin, and perinatal history (e.g., prematurity) are proxies for healthcare fragmentation and unequal resources. The intersection of race and poverty likely amplifies risks.

C. Need for Systems-Level Interventions

Enhance equity in post-operative follow-up and early complication detection. Implement community-based interventions and education programs to support families from underserved populations. Broaden inclusion of socioeconomic variables in large-scale registries like HCRN to better understand root causes.

Conclusions

The consistent signal across studies — that racial and socioeconomic disparities affect outcomes in pediatric hydrocephalus — underscores an urgent need for targeted policy, educational, and clinical interventions. The findings from the HCRN dataset should galvanize the neurosurgical community to address not only technical outcomes but also systemic inequities in pediatric neurosurgical care.

1)

Rocque BG, Jensen H, Reeder RW, Rozzelle CJ, Kulkarni AV, Pollack IF, McDowell MM, Naftel RP, Jackson EM, Whitehead WE, Pindrik JA, Isaacs AM, Strahle JM, McDonald PJ, Tamber MS, Hankinson TC, Browd SR, Hauptman JS, Krieger MD, Chu J, Riva-Cambrin J, Limbrick DD, Holubkov R, Kestle JRW, Wellons JC. Racial disparities in hydrocephalus mortality and shunt revision: a study from the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr. 2025 Mar 21:1-9. doi: 10.3171/2024.12.PEDS24371. Epub ahead of print. PMID: 40117669.
2)

Ghaffari-Rafi A, Gorenflo R, Hu H, Viereck J, Liow K. Role of psychiatric, cardiovascular, socioeconomic, and demographic risk factors on idiopathic normal pressure hydrocephalus: A retrospective case-control study. Clin Neurol Neurosurg. 2020 Jun;193:105836. doi: 10.1016/j.clineuro.2020.105836. Epub 2020 Apr 28. PMID: 32371292.
3)

Jin DL, Christian EA, Attenello F, Melamed E, Cen S, Krieger MD, McComb JG, Mack WJ. Cross-Sectional Analysis on Racial and Economic Disparities Affecting Mortality in Preterm Infants with Posthemorrhagic Hydrocephalus. World Neurosurg. 2016 Apr;88:399-410. doi: 10.1016/j.wneu.2015.12.046. Epub 2015 Dec 28. PMID: 26732967.
4)

Attenello FJ, Ng A, Wen T, Cen SY, Sanossian N, Amar AP, Zada G, Krieger MD, McComb JG, Mack WJ. Racial and socioeconomic disparities in outcomes following pediatric cerebrospinal fluid shunt procedures. J Neurosurg Pediatr. 2015 Jun;15(6):560-6. doi: 10.3171/2014.11.PEDS14451. Epub 2015 Mar 20. PMID: 25791773.
5)

Walker CT, Stone JJ, Jain M, Jacobson M, Phillips V, Silberstein HJ. The effects of socioeconomic status and race on pediatric neurosurgical shunting. Childs Nerv Syst. 2014 Jan;30(1):117-22. doi: 10.1007/s00381-013-2206-5. Epub 2013 Jun 30. PMID: 23811830.

Neuroendoscopic lavage for periventricular-intraventricular hemorrhage

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Neuroendoscopic lavage for periventricular-intraventricular hemorrhage

J.Sales-Llopis

Neurosurgery Department, General University Hospital Alicante, Spain

Neuroendoscopic lavage for periventricular-intraventricular hemorrhage (PIVH) is an emerging surgical approach aimed at improving the clearance of intraventricular blood clots, reducing hydrocephalus, and improving neurological outcomes in affected patients. Here’s an overview of the technique and its implications:

Indications

Neuroendoscopic lavage is typically indicated in cases of:

1. Severe intraventricular hemorrhage (IVH) associated with periventricular hemorrhage.

2. Obstructive hydrocephalus caused by blood clots in the ventricular system.

3. Cases where conservative management or external ventricular drainage (EVD) alone is insufficient for clot resolution.

Procedure

The procedure involves using a neuroendoscope to directly access the ventricular system. Key steps include:

1. Ventricular access: A burr hole is created to access the affected ventricle under neuronavigation guidance.

2. Neuroendoscopic insertion: A flexible or rigid endoscope is introduced into the ventricle.

3. Clot removal: Blood clots are aspirated or fragmented under direct visualization using specialized instruments or saline irrigation.

4. Irrigation: The ventricles are irrigated with warmed saline to ensure clearance of debris and residual clots.

5. EVD placement: Often, an external ventricular drain is left in place to monitor intracranial pressure (ICP) and facilitate further drainage of blood or cerebrospinal fluid (CSF).

Advantages

1. Enhanced clot clearance: Direct visualization allows for targeted and effective removal of clots, reducing clot burden and the associated risk of persistent hydrocephalus.

2. Reduced inflammation: By removing blood and its breakdown products, neuroendoscopic lavage may decrease the inflammatory response that contributes to ventricular scarring and hydrocephalus.

3. Minimally invasive: Compared to open surgical approaches, it involves smaller incisions and reduced disruption of brain tissue.

4. Potential for improved outcomes: Studies have suggested better neurological recovery and lower rates of shunt dependency in some cases.

Challenges and Limitations

1. Technical expertise: The procedure requires advanced neuroendoscopic skills and specialized equipment.

2. Risks: Complications include infection, hemorrhage, or damage to ventricular structures.

3. Not universally applicable: It is most effective in cases where clot consistency and location are suitable for endoscopic removal.

4. Limited evidence: While promising, robust clinical trials are needed to establish its efficacy compared to standard treatments.

Outcomes

– Early studies indicate that neuroendoscopic lavage can reduce mortality and improve functional outcomes in patients with PIVH and hydrocephalus.

– It may decrease the need for permanent CSF shunting and lower rates of complications related to prolonged EVD use.

Future Directions

1. Standardization: Developing standardized protocols for patient selection and procedural techniques.

2. Technological advances: Innovations in endoscopic tools and navigation systems to enhance safety and efficacy.

3. Long-term studies: Further research to evaluate the long-term benefits and cost-effectiveness of neuroendoscopic lavage.

The current neurosurgical procedure for periventricular-intraventricular hemorrhage resulting in posthemorrhagic hydrocephalus (PHH) seeks to reduce intracranial pressure with temporary and then Cerebrospinal fluid shunt. In contrast, neuroendoscopic lavage (NEL) directly addresses the intraventricular blood that is hypothesized to damage the ependyma and parenchyma, leading to ventricular dilation and hydrocephalus.

Systematic reviews

Wassef et al. conducted a systematic review of the literature on neuroendoscopic lavage in IVH of prematurity to examine data on the choice of neuroendoscope and outcomes regarding shunt rate. They then collected manufacturer data on neuroendoscopic devices, including inflow and outflow mechanisms, working channel specifications, and tools compatible with the working channel. We paired this information with the advantages and disadvantages reported in the literature and observations from the experiences of pediatric neurosurgeons from several institutions to provide a pragmatic evaluation of international clinical experience with each neuro endoscope in NEL.

Eight studies were identified; four neuroendoscopes have been used for NEL as reported in the literature. These include the Karl Storz Flexible Neuroendoscope, LOTTA® system, GAAB system, and Aesculap MINOP® system. The LOTTA® and MINOP® systems were similar in setup and instrument options. Positive neuroendoscope features for NEL include increased degrees of visualization, better visualization with the evolution of light and camera sources, the ability to sterilize with autoclave processes, balanced inflow and outflow mechanisms via separate channels, and a working channel. Neuroendoscope disadvantages for NEL may include special sterilization requirements, large outer diameter, and limitations in working channels.

A neuroendoscope integrating continuous irrigation, characterized by measured inflow and outflow via separate channels and multiple associated instruments, appears to be the most commonly used technology in the literature. As neuro endoscopes evolve, maximizing clear visualization, adequate inflow, measured outflow, and large enough working channels for paired instrumentation while minimizing the footprint of the outer diameter will be most advantageous when applied for NEL in premature infants 1).

Wassef et al.’s review provides an essential contribution to the understanding of neuroendoscopic technology in the context of NEL for IVH in premature infants. While the study outlines critical device features and evolving trends, its conclusions are constrained by limited data and a lack of quantitative analysis. Nevertheless, the work highlights key priorities for technological and clinical advancement, serving as a foundation for future research and innovation in this challenging yet promising area of pediatric neurosurgery.

Retrospective cohort studies

The records of patients with a diagnosis of grade III or IV IVH were reviewed between September 2022 and February 2024. The Papile-Burstein classification grade was determined on cranial ultrasonography. Demographic information collected included gestational age, birth weight, weight at the time of surgical intervention, infection confirmed with CSF, and hemorrhage. Standard local guidelines for temporary (CSF reservoir) and permanent (shunt or endoscopic third ventriculostomy (ETV) CSF diversion was implemented. Warmed Lactated Ringer’s was utilized for NEL. The primary outcome was the need for permanent CSF diversion (shunt or ETV).

Twenty consecutive patients with grade III or IV IVH complicated by PHH were identified. Twelve patients underwent CSF reservoir placement and NEL, 4 underwent CSF reservoir placement only, 1 underwent shunt placement only, and 3 did not require neurosurgical intervention. Of the 12 patients who underwent reservoir placement and NEL, 8 (67%) ultimately met the criteria for permanent CSF diversion compared with 2 of 4 (50%) who underwent CSF reservoir placement only. The mean gestational age at birth, birth weights, and age/weight at the time of temporary CSF diversion were similar across groups. The average time interval between temporary and permanent CSF diversion was longer in patients who underwent NEL (2.5 months for shunt and 6.5 months for ETV) compared with CSF reservoir placement only (1.1 months).

NEL is an innovative alternative for the treatment of PHH of prematurity. Flanders et al. from the New York University Grossman School of Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Pennsylvania established an endoscopic lavage program at their institution and herein report the first published account in the United States of the feasibility of NEL for PHH 2).

Flanders et al. provide an intriguing glimpse into the potential of neuroendoscopic lavage for managing PHH of prematurity. While the approach is innovative and technically feasible, the study’s small sample size, lack of randomization, and limited long-term outcome data temper the enthusiasm for immediate adoption. Further research is essential to confirm the efficacy, safety, and cost-effectiveness of NEL, ensuring its role as a viable alternative or adjunct to existing treatment paradigms for PHH.

Comparative retrospective studies

Between August 2010 and December 2012 (29 months), 19 neonates with posthemorrhagic hydrocephalus underwent neuroendoscopic lavage for removal of intraventricular blood remnants. During a similar length of time (29 months) from March 2008 to July 2010, 10 neonates were treated conventionally, initially using temporary CSF diversion via lumbar punctures, a ventricular access device, or an external ventricular drain. Complications and shunt dependency rates were evaluated retrospectively. Results The patient groups did not differ regarding gestational age and birth weight. In the endoscopy group, no relevant procedure-related complications were observed. After the endoscopic lavage, 11 (58%) of 19 patients required a later shunt insertion, as compared with 100% of infants treated conventionally (p < 0.05). Endoscopic lavage was associated with fewer numbers of overall necessary procedures (median 2 vs 3.5 per patient, respectively; p = 0.08), significantly fewer infections (2 vs 5 patients, respectively; p < 0.05), and supratentorial multiloculated hydrocephalus (0 vs 4 patients, respectively; p < 0.01) [corrected]. Conclusions Within the presented setup the authors could demonstrate the feasibility and safety of neuro-endoscopic lavage for the treatment of posthemorrhagic hydrocephalus in neonates with IVH. The nominally improved results warrant further verification in a multicenter, prospective study 3).

The study provides a compelling case for the feasibility and safety of neuroendoscopic lavage in neonates with posthemorrhagic hydrocephalus. The lower rates of shunt dependency, infections, and multiloculated hydrocephalus are encouraging and suggest a potential benefit of NEL over conventional management.

However, the study’s limitations, particularly its retrospective design, small sample size, and lack of long-term outcomes, necessitate further investigation. A multicenter, prospective study is critical to validate these findings, optimize patient selection, and determine the technique’s broader applicability and impact on long-term neurodevelopment.

This study represents a promising step forward, but cautious interpretation is essential until more robust evidence emerges.

1)

Wassef CE, Thomale UW, LoPresti MA, DeCuypere MG, Raskin JS, Mukherjee S, Aquilina K, Lam SK. Experience in endoscope choice for neuroendoscopic lavage for intraventricular hemorrhage of prematurity: a systematic review. Childs Nerv Syst. 2024 Aug;40(8):2373-2384. doi: 10.1007/s00381-024-06408-6. Epub 2024 May 27. PMID: 38801444; PMCID: PMC11269422.
2)

Flanders TM, Hwang M, Julian NW, Sarris CE, Flibotte JJ, DeMauro SB, Munson DA, Heimall LM, Collins YC, Bamberski JM, Sturak MA, Storm PB, Lang SS, Heuer GG. Neuroendoscopic lavage for posthemorrhagic hydrocephalus of prematurity: preliminary results at a single institution in the United States. J Neurosurg Pediatr. 2025 Jan 24:1-8. doi: 10.3171/2024.10.PEDS24119. Epub ahead of print. PMID: 39854725.
3)

Schulz M, Bührer C, Pohl-Schickinger A, Haberl H, Thomale UW. Neuroendoscopic lavage for the treatment of intraventricular hemorrhage and hydrocephalus in neonates. J Neurosurg Pediatr. 2014 Jun;13(6):626-35. doi: 10.3171/2014.2.PEDS13397. Epub 2014 Apr 4. Erratum in: J Neurosurg Pediatr. 2014 Jun;13(6):706. PMID: 24702621.

Follow up of infants with skull fractures by neurosurgeons due to the risk of growing fractures; is it needed?

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The article “Follow up of infants with skull fractures by neurosurgeons due to the risk of growing fractures; is it needed?” published in *Br J Neurosurg* provides a retrospective analysis of skull fractures in infants under one year of age and aims to determine the necessity of follow-up for those at risk of growing skull fractures. While the study touches on a potentially important issue in pediatric neurosurgery, it suffers from numerous critical weaknesses, rendering its conclusions unsubstantiated and ultimately unconvincing.

Firstly, the methodology of the study is deeply flawed. The authors utilize a single-center retrospective design, which inherently limits the generalizability of the results. The absence of referral data from 2008-2013 further undermines the reliability of the findings, as it introduces a significant gap in the dataset. The small sample size (n=246) and the even smaller subset of patients who developed growing skull fractures (n=2) further exacerbate this issue, making it difficult to draw any meaningful conclusions about risk factors or the need for follow-up care. The study’s reliance on a small number of cases renders its results statistically insignificant and unrepresentative of the larger population.

Moreover, the study presents a highly superficial analysis of the factors associated with growing skull fractures. While the authors note a significant difference in fracture splay distance and elevation/depression distance, these variables alone are insufficient to predict the development of a growing skull fracture. The study fails to consider a broad range of potential confounders, such as underlying genetic factors, comorbidities, or the presence of other cranial injuries, that could influence the likelihood of fracture progression. This lack of comprehensive data analysis weakens the study’s conclusions and renders the identified risk factors (fracture displacement over 4mm and elevation/depression distance over 3mm) overly simplistic.

The study’s findings also raise serious questions about the clinical relevance of its results. The authors suggest that resources and investigations should focus on children with fractures that exceed specific thresholds in displacement and elevation/depression, which seems like a reasonable approach at first glance. However, the study does not provide adequate evidence to support this recommendation. With only two cases of growing skull fractures in the entire sample, the claim that these thresholds are indicative of a “significantly greater risk” is premature and unsubstantiated. The low incidence of growing skull fractures in the study (a mere 1.1% of the total sample) calls into question whether follow-up for all fractures, regardless of severity, is justified.

Furthermore, the authors make sweeping recommendations about resource allocation based on minimal data, failing to acknowledge the potential risks of overtreatment. With so few cases of growing skull fractures observed, it is highly questionable whether the vast resources and investigations required to follow up on every infant with a skull fracture are justified. The study does not adequately address the costs, both in terms of healthcare resources and patient well-being, associated with frequent follow-ups for an extremely rare condition.

Lastly, the study’s conclusions lack critical perspective. While the authors recommend focusing on infants with fractures meeting certain criteria, they fail to adequately discuss the potential harms of over-monitoring and over-intervention. It is essential to balance the need for follow-up with the avoidance of unnecessary medical interventions, particularly when dealing with vulnerable populations such as infants.

In conclusion, while the study raises an important clinical question, it ultimately fails to provide robust evidence to justify its claims. The flawed methodology, small sample size, lack of comprehensive data analysis, and unsubstantiated recommendations make this paper far from conclusive. The need for follow-up in cases of skull fractures in infants remains an open question, and this study does little to advance our understanding of which children truly require ongoing monitoring. Without more rigorous research, the recommendations presented in this study should be viewed with caution and skepticism.