Samuel A. Tenhoeve

Objective: Use of neuromodulation strategies targeting thalamic nuclei, including deep brain stimulation (DBS) and responsive neurostimulation (RNS), for treatment of pediatric drug‐resistant epilepsy (DRE) is increasing, despite limited evidence for efficacy and safety. We present the initial results from the Comparative Multicenter Evaluation of Thalamic Neuromodulation for Treatment‐Resistant Epilepsy in Children consortium, which was created to study thalamic modulation in children with DRE. Methods: We performed a retrospective cohort study of children who underwent thalamic DBS or RNS for DRE between January 2015 and December 2024 across 12 centers. Primary outcomes were percent seizure reduction, Engel class, and responder rates (>50% seizure reduction) at 3, 6, and 12 months postoperatively. Secondary outcomes included antiseizure medications and surgical complications. Differences were quantified using ordinal logistic regression, generalized estimating equations with center clustering, and mixed‐effects models. Stratified analyses were performed by thalamic target (centromedian vs. anterior nucleus) and epilepsy diagnosis (Lennox–Gastaut syndrome, generalized, focal, and multifocal). Results: Among the 221 included patients (111 DBS, 110 RNS) included, DBS and RNS achieved comparable Engel scores and 12‐month responder rates, but different temporal trajectories were observed. There was a significant device × time interaction (odds ratio = 1.10/month, 95% confidence interval = 1.01–1.20, p = .04), with RNS response rates increasing from 26.9% at 3 months to 55.6% at 12 months (paired p < .001) but with DBS response rates reaching 41.7% at 3 months and remaining comparatively stable over time. DBS achieved significantly higher 12‐month seizure freedom (9.5% vs. 1.2%, p = .03). Neither thalamic target selection nor diagnosis predicted seizure outcome. Safety profiles were equivalent. Significance: This multicenter analysis provides pediatric‐specific data to inform surgical indications, device selection, and preoperative counseling. DBS and RNS were effective for treatment of pediatric DRE, with equivalent 12‐month seizure outcomes but different temporal trajectories. DBS provided earlier seizure control and higher rates of overall seizure freedom.

Purpose Glioblastoma (GBM) is an aggressive primary brain tumor with poor overall survival. Patients living in rural areas have worse outcomes than those in metropolitan regions, but the effect of distance from subspecialty care on survival and clinical trial participation remains unclear. We evaluated the association between distance to a National Cancer Institute–designated Comprehensive Cancer Center (CCC) and overall survival (OS) and clinical trial enrollment in patients with isocitrate dehydrogenase wild-type GBM. Methods We retrospectively identified patients with newly diagnosed isocitrate dehydrogenase wild-type GBM (2021 World Health Organization classification) who received treatment at our CCC (2018–2022). Distance from the CCC was analyzed as both categorical and continuous variables. Univariable and multivariable Cox regression models were performed, adjusting for established prognostic factors. Results The 167 patients had similar baseline characteristics across distance groups. In univariable analyses, no significant difference in OS was observed between patients living near the CCC and those at intermediate or far distances. In multivariable analysis, patients in the intermediate-distance group demonstrated significantly worse OS compared with the near group (hazard ratio 1.61, 95% confidence interval 1.03, 2.50, p = 0.035). Increasing distance was associated with significantly lower clinical trial enrollment (near 43%, intermediate 35%, and far 18%; p = 0.0001). Conclusions Distance from a CCC was associated with disparities in survival and access to clinical trials among patients with isocitrate dehydrogenase wild-type GBM. Given that clinical trials represent a standard-of-care option for GBM, strategies to improve access to subspecialty care and trial participation are needed to reduce outcome disparities.

Patients with spinal metastasis often benefit from surgical intervention for debulking to improve neurologic deficits, reduce spinal cord or root compression, and ameliorate pain. Traditionally, large, open fusions have been used to achieve adequate decompression of neural structures. These types of interventions are frequently associated with significant blood loss, prolonged hospitalizations, and increased risk of surgery-related complications, which can delay postoperative chemotherapy and radiation therapies. Endoscopic spine approaches allow access to the spinal cord and nerve roots with minimal soft tissue disruption, which has been shown to reduce risks associated with open surgery in other contexts. Furthermore, the smaller incision, reduced blood loss, ability to position incisions away from radiation fields, and lower risk profile in high-risk patients may provide an effective solution to spinal metastases in appropriately selected cases. Here, we present two cases of spinal metastases successfully managed with spinal endoscopy and recommend the consideration of this approach for similar scenarios.

Background: Social determinants of health (SDOHs) may impact outcomes of patients with high-grade glioma (HGG). We examined the effect of rurality and socioeconomic status on treatment and survival of patients with newly diagnosed HGG. Methods: This retrospective analysis used 2 cohorts from the Utah Cancer Registry, including all patients diagnosed with HGG (2000-2019) (cohort 1) and all HGG patients who underwent surgery (2000-2020) (cohort 2). Patient demographics were evaluated descriptively. Kaplan-Meier curves, log-rank tests, and multivariable Cox regression analysis were used for survival analyses. Results: Patients from cohort 1 living in Frontier (n = 60), Rural (n = 363), and Urban (n = 1502) Utah traveled mean distances of 95.9 ± 69.7, 50.0 ± 66.5, and 10.7 ± 11.3 miles, respectively, for treatment (P < .001). Urban patients were diagnosed at a younger age (54.2 ± 20.2 years) than patients from Frontier (56.8 ± 20.3 years) and Rural (57.3 ± 17.6 years) areas (P < .019). Frontier patients were more likely to have lower income than Urban patients (30.7% vs 65.5%, P < .001). Rural patients (13.0 months [95% CI 11.2-14.8]) experienced shorter median survival than Urban patients (16 months [95% CI 14.3-17.7]) (P = .049). Among patients undergoing surgery, those with private insurance (54.2%, P < .001) and in high-income (60.2%, P = .007) and socioeconomic (60.4%, P = .005) quartiles received adjuvant chemotherapy and radiation more frequently. Conclusion: HGG patients from Frontier and Rural counties in Utah encountered greater SDOH barriers without experiencing delays in resection. Rural patients had shorter survival than Urban patients. Further investigation is needed to determine whether additional SDOHs (income and insurance status) may intersect and contribute to shorter survival and less access to adjuvant therapy.

The integration of biologics in endovascularly treated intracranial aneurysms is a significant area of focus in an evolving field. By presenting the clinical relevance, pathogenesis, management (historical and current), and emerging biologics themselves, this work provides a broad overview of the current landscape of the biologics under current investigation. Growth factors, cytokines, and biologic-coated coils are compared and described as modalities to increase healing, aneurysm occlusion, and long-term recovery. These emerging biologics may increase the efficacy and durability of less invasive endovascular methods and potentially change standard practice with continued exploration.

Purpose: Tethered cord syndrome (TCS) is characterized by abnormal attachment of the spinal cord neural elements to surrounding tissues. The most common symptoms include pain, motor or sensory dysfunction, and urologic deficits. Although TCS is common in children, there is a significant heterogeneity in outcomes reporting. We systematically reviewed surgical indications and postoperative outcomes to assess the need for a grading/classification system. Methods: PubMed and EMBASE searches identified pediatric TCS literature published between 1950 and 2023. Studies reporting surgical interventions, ≥ 6-month follow-up, and ≥ 5 patients were included. Results: Fifty-five studies representing 3798 patients were included. The most commonly reported non-urologic symptoms were nonspecific lower-extremity motor disturbances (36.4% of studies), lower-extremity/back pain (32.7%), nonspecific lower-extremity sensory disturbances (29.1%), gait abnormalities (29.1%), and nonspecific bowel dysfunction/fecal incontinence (25.5%). Urologic symptoms were most commonly reported as nonspecific complaints (40.0%). After detethering surgery, retethering was the most widely reported non-urologic outcome (40.0%), followed by other nonspecific findings: motor deficits (32.7%), lower-extremity/back/perianal pain (18.2%), gait/ambulation function (18.2%), sensory deficits (12.7%), and bowel deficits/fecal incontinence (12.7%). Commonly reported urologic outcomes included nonspecific bladder/urinary deficits (27.3%), bladder capacity (20.0%), bladder compliance (18.2%), urinary incontinence/enuresis/neurogenic bladder (18.2%), and nonspecific urodynamics/urodynamics score change (16.4%). Conclusion: TCS surgical literature is highly variable regarding surgical indications and reporting of postsurgical outcomes. The lack of common data elements and consistent quantitative measures inhibits higher-level analysis. The development and validation of a standardized outcomes measurement tool—ideally encompassing both patient-reported outcome and objective measures—would significantly benefit future TCS research and surgical management.