Archives of Pediatric Neurosurgery

Long-term Results of Stereotactic Radiofrequency Surgery for Aggressive Behavioral in Obsessive-Compulsive Adolescent – A 10-Year Follow-up Case Report

Walter Fagundes — 2026-04-10

Introduction: Aggressive and self-injurious behaviors associated with obsessive-compulsive disorder in patients with intellectual disability represent a major therapeutic challenge, particularly in cases refractory to pharmacological and behavioral treatment. In this context, stereotactic neurosurgery has been considered a last-resort option, targeting limbic and paralimbic circuits involved in emotional and behavioral regulation.

Case Report: We report the case of a 17-year-old male with pharmacological resistant obsessive-compulsive disorder and severe mental retardation, with a 9-year history of refractory aggressive behavior, who underwent stereotactic neurosurgical intervention in 2006. Preoperatively, the patient exhibited high levels of aggression (MOAS score: 31). Postoperatively, there was a complete and sustained remission of aggressive episodes, with MOAS scores of 0 at all follow-up intervals up to 10 years. The patient also experienced marked improvement in obsessive-compulsive symptoms, reduction in psychotropic medications, and significant enhancement in attention, concentration, quality of life, and family satisfaction. One wound infection was reported postoperatively, with no lasting adverse effects.

Conclusion: This case highlights the potential for stereotactic lesioning to induce profound and durable behavioral improvements in select patients with treatment-refractory aggression.

Surgical treatment of unilateral lambdoid craniosynostosis with revolution spiral osteotomy: a case report

Angelo Silva Neto — 2026-04-14

Introduction/Background: Lambdoid craniosynostosis (LC) is the premature fusion of the unilateral or bilateral lambdoid suture. It is a rare condition associated with neurodevelopmental implications across different ages. Therefore, early diagnosis and treatment are crucial for a positive outcome.

Case Presentation: Here, we report the case of an 11-month-old male patient diagnosed with LC, presenting facial shift and altered ear positioning consistent with the condition. For the case, we employed the revolution spiral technique, a less invasive corrective method that minimizes bone loss and reduces postoperative morbidity. The patient showed no complications during surgery and was then evaluated 3 months after surgery, showing correction of the cranial deformity and no procedure-related complications.

Conclusions : We propose the revolution spiral technique as an effective alternative for the surgical management of LC, with minimal associated risks.

Delayed Chronic Subdural Hematoma Associated with Temporal Arachnoid Cyst in Children: A Rare Case Report and Literature Review

Hoai Dinh TP. — 2026-05-15

Introduction: Chronic subdural hematoma (cSDH) is uncommon in children and even rarer when associated with congenital arachnoid cysts. This coexistence poses diagnostic and therapeutic challenges because the initial trauma and imaging findings are often insignificant or normal

Case Presentation: An 11-year-old previously healthy boy presented with progressive headache and vomiting three months after a minor head injury. Initial brain CT immediately after the trauma was completely normal. On admission, a new CT scan revealed a left chronic subdural hematoma (17 mm thick, 12 mm midline shift) compressing the ipsilateral ventricle, together with a well-defined left temporal arachnoid cyst (38 × 22 × 44 mm). Burr-hole evacuation of the hematoma was performed under general anesthesia, without manipulation of the cyst. The postoperative course was uneventful, and the follow-up CT scan confirmed complete resolution

Conclusions: Even minor head trauma in children with temporal arachnoid cysts can lead to delayed chronic subdural hematoma. Burr-hole evacuation alone provides excellent outcomes, and cyst fenestration is not always required. Recognizing this rare association is crucial for early diagnosis and optimal management.

Posterior Fossa Epidural Hematoma: A Case Report

Lucas Rodrigues Olmedo — 2026-05-15

Introduction/Background:

Posterior fossa epidural hematoma (PFEDH) is a rare entity within pediatric traumatic brain injury, characterized by blood accumulation between the dura mater and skull in the infratentorial compartment. Despite its low incidence, PFEDH carries significant risk due to the limited compliance of the posterior fossa, which may lead to brainstem compression, hydrocephalus, and rapid neurological deterioration. Clinical presentation is often subtle and nonspecific, contributing to delayed diagnosis and increased morbidity.

Case Presentation:

A previously healthy 4-year-old girl presented with persistent vomiting following occipital head trauma after a fall. Initial evaluations misdiagnosed the condition as gastroenteritis, delaying neuroimaging. Progressive symptoms, including drowsiness and prostration, prompted cranial computed tomography, which revealed a posterior fossa epidural hematoma (4.3 × 3.0 × 1.8 cm) associated with ventriculomegaly and signs of intracranial hypertension. Despite a Glasgow Coma Scale score of 15 and absence of focal deficits, surgical intervention was indicated due to mass effect and cerebrospinal fluid obstruction. The patient underwent occipital craniotomy with hematoma evacuation. The postoperative course was uneventful, with rapid clinical improvement and complete recovery at follow-up.

Conclusions:

PFEDH may present with nonspecific symptoms in pediatric patients, increasing the risk of diagnostic delay. This case highlights the importance of maintaining a high index of suspicion and early use of neuroimaging in children with persistent vomiting after head trauma. Prompt surgical management, even in neurologically stable patients, can lead to excellent outcomes and prevent severe complications.

The Burden of Ventriculoperitoneal Shunt Complications: A Quest for Standardization

Emmanuel Garba Sunday — 2026-05-15

Background: Ventriculoperitoneal shunt (VPS) placement is the main treatment for hydrocephalus, but infection and malfunction remain important concerns, particularly where standardized insertion protocols are limited. This study describes VPS-related complications after implementation of a standardized perioperative protocol in two Nigerian tertiary hospitals.

Methods: We conducted a prospective descriptive cohort study from December 1, 2023, to October 31, 2025. Consecutive patients with hydrocephalus requiring VPS were enrolled. The protocol included morning scheduling with neonatal priority, povidone-iodine skin preparation, prophylactic antibiotics, double gloving, minimal shunt handling, delayed shunt opening, and limited skin contact. Sociodemographic, clinical, radiologic, operative, and outcome data were analyzed descriptively. Early complications were defined as events occurring within 6 months after surgery.

Results: Ninety VPS procedures were performed in 87 patients; two were lost to follow-up. Median age was 4 years (IQR, 1–16; range, 0.08–43), and 62.1% were male. Non-communicating hydrocephalus was most common (64.4%), mainly due to congenital aqueductal stenosis. Overall complication rate was 3.33% (n=3), including two proximal obstructions and one transanal protrusion. The latter occurred in a premature, malnourished neonate who developed meningitis and died after revision, corresponding to an infection rate of 1.11% per procedure. Median hospital stay was 5 days (IQR, 4–6), and median follow-up was 4 months (range, 1–19).

Conclusions: A standardized VPS insertion protocol was associated with low complication and infection rates. However, causal inference is limited by the descriptive design and bundled intervention. Comparative studies with longer follow-up are needed.

Teaching the Next Generation: Advances in Neurosurgical Education

Matheus Ballestero — 2026-05-15

Neurosurgery is a highly complex surgical specialty with one of the longest and most demanding learning curves in all of medicine — one in which patient safety is not merely an ethical imperative but the organizing principle of the entire educational process. Since the first formal residency programs were established by William Osler and William Stewart Halsted at Johns Hopkins Hospital in Baltimore, this structured training model has expanded worldwide and become the gold standard for surgery education. Harvey Cushing, widely regarded as the father of modern neurosurgery, built upon this foundation to establish neurosurgery as a distinct discipline, training a generation of surgeons who carried his standards across the country and around the world. Arthur E. Walker later formalized this legacy by creating the world's first dedicated neurosurgery residency program at the same institution.

For much of the twentieth century, the philosophy underpinning surgical education was elegantly captured in the dictum attributed to Halsted: "See One, Do One, Teach One." In its time, this framework was transformative. Today, however, the conditions under which surgical competence can be developed through traditional methods have changed profoundly. Reduced surgical caseloads, evolving ethical standards governing patient care, and mandatory restrictions on residents' weekly working hours have created a structural tension at the heart of surgical training: the demand for technically excellent, clinically confident neurosurgeons has not diminished, but the traditional pathways for producing them have been significantly constrained. Modern residency programs have responded by placing increasing emphasis on simulation-based training before direct patient interaction — a shift that is reshaping the culture and infrastructure of neurosurgical education worldwide.

Simulation in neurosurgery serves two complementary and equally important functions. The first is clinical planning: technologies such as virtual reality, augmented reality, and three-dimensional printing allow surgical teams to reconstruct patient-specific anatomical models and rehearse complex or unusual procedures before entering the operating room. This application is particularly valuable in rare or anatomically challenging conditions, where prior exposure to similar cases may be limited and the consequences of intraoperative surprises can be severe. In many instances, a simulation is developed specifically for a single complex case, functioning simultaneously as a planning instrument and a rehearsal environment. The second function is educational, and it is here that the field has seen its most dynamic growth. Cadaveric dissection, purpose-built surgical simulators, scenario-based learning, and structured competency frameworks now form the backbone of progressive neurosurgical training programs, allowing the principles of deliberate practice to be applied with a frequency and intentionality that the traditional operating room rarely permits.

Within this landscape, pediatric neurosurgery has emerged as a particularly arena for innovation. The relative rarity of many pediatric neurosurgical conditions, their concentration in specialized centers, and the unique anatomical and physiological characteristics of the developing nervous system make supplementary simulation training not merely beneficial but essential. The development, implementation, and rigorous validation of multiple simulation platforms in this subspecialty have placed pediatric neurosurgery at the vanguard of technological innovation in neurosurgical surgical education. Most significantly, the integration of artificial intelligence into simulation environments is beginning to transform training from a passive rehearsal experience into an adaptive, personalized learning system — one capable of analyzing trainee performance with granular precision, identifying specific areas of weakness, and adjusting the focus and difficulty of training tasks in real time to optimize each individual's learning trajectory.

It is in direct response to these developments, and in the spirit of the educational tradition that stretches from Halsted and Cushing to the present day, that the book “Advanced Teaching Methods in Neurological Surgery” is currently in its final stages of preparation. The volume provides a comprehensive and practically oriented overview of innovative approaches to neurosurgical education, integrating foundational principles of medical and surgical pedagogy with the full spectrum of emerging technologies. It addresses curriculum design, competency-based assessment, cadaveric dissection, surgical simulation, scenario-based learning, and the growing role of artificial intelligence, augmented reality, and virtual reality in both teaching and evaluation. It is intended as a valuable resource for educators, program directors, residents, and medical students — offering practical strategies to enhance technical skills, clinical decision-making, and patient safety in the context of modern neurosurgical training.

The history of neurosurgery is, in a profound sense, a history of education. The challenge facing neurosurgical educators today remains fundamentally the same one Harvey Cushing faced more than a century ago: how to prepare the next generation of surgeons to deliver the highest standard of care to patients who trust them with the most complex organ in the human body. The tools available to meet that challenge now extend far beyond what Cushing or Walker could have imagined — yet the values they embodied, precision, dedication, and commitment to the patient, remain as relevant today as they were at the founding of our specialty.

The Editors Pediatric Neurosurgery

Comments on “Surgical treatment of unilateral lambdoid craniosynostosis with revolution spiral osteotomy: a case report

Ricardo Santos de Oliveira — 2026-05-15

To the Editor,

We read with great interest the case report by Silva Neto et al. describing the surgical management of presumed unilateral lambdoid craniosynostosis using a revolution spiral osteotomy associated with absorbable plates. The authors are to be congratulated for sharing their experience with a rare and challenging condition, as well as for presenting an innovative technical approach for posterior cranial vault remodeling. Reports such as this are valuable because they stimulate discussion on both diagnosis and surgical strategy in uncommon forms of craniosynostosis.

At the same time, we would like to respectfully offer a few comments that may further enrich the interpretation of this case. True posterior plagiocephaly caused by unilateral lambdoid synostosis is exceptionally rare, and for this reason a particularly careful distinction from deformational plagiocephaly is essential. In our view, the diagnostic documentation presented in the article could be strengthened to more clearly support right lambdoid synostosis.

From an imaging perspective, the article includes limited tomographic illustration, and the published material does not seem to unequivocally demonstrate fusion of the right lambdoid suture. In such cases, three-dimensional CT reconstruction can be especially helpful, both to document the site of synostosis and to allow readers to better appreciate the anatomical basis for the diagnosis. Because lambdoid synostosis is so uncommon, more complete radiological demonstration would significantly reinforce the message of the report.

We also believe that additional detail in the clinical history would be valuable. Specifically, it would be helpful to know whether the cranial asymmetry had been noticed since birth. This point is important because congenital onset tends to support true craniosynostosis, whereas postnatal development may raise the possibility of a positional or deformational process. Similarly, although the authors describe relevant findings, the clinical images do not clearly allow identification of the classical external features associated with true posterior plagiocephaly, such as mastoid prominence, skull-base asymmetry, characteristic ear displacement, and contralateral parietal bossing.

Another aspect that deserves consideration is the possibility of pseudo-ridging. Deformational plagiocephaly may occasionally present with a palpable ridge that can resemble the bony prominence associated with a fused suture. For this reason, when the diagnosis is unilateral lambdoid synostosis, correlation among physical examination, detailed imaging, and, ideally, 3D reconstruction becomes especially important. In our opinion, this distinction would be particularly relevant in the present report, since the published photograph alone does not make it easy for the reader to identify the clinical hallmarks of true posterior plagiocephaly or to confidently exclude a postural deformity.

With regard to the surgical technique, the use of the revolution spiral osteotomy is interesting and certainly adds originality to the case. We would, however, appreciate further clarification regarding the rationale for using absorbable plates in association with this technique. In cases of true posterior craniosynostosis, correction may often be achieved either by distraction through a linear osteotomy and gradual advancement—accepting the need for distractor removal after a few months—or by a more conventional unilateral osteotomy and advancement stabilized with absorbable fixation. Within the context of the spiral osteotomy construct itself, the precise additional contribution of absorbable plates is not entirely clear, and a more detailed explanation of this choice would be educational for readers.

This question is relevant because broader craniosynostosis experience has consistently shown that lambdoid synostosis represents only a small fraction of surgically treated cases, underscoring the importance of rigorous diagnostic confirmation before proposing technical innovations in this subgroup. Likewise, the literature on posterior cranial vault expansion highlights the importance of detailed imaging analysis and individualized surgical planning in posterior cranial deformities.

In summary, we believe this case report makes a welcome contribution by drawing attention to a rare pathology and by presenting a creative operative solution. We respectfully suggest, however, that stronger radiological demonstration of the lambdoid synostosis, more explicit information regarding the onset of the deformity, and a clearer discussion of the differential diagnosis with deformational plagiocephaly would further strengthen the report. Additional clarification regarding the role of absorbable plates in the spiral osteotomy technique would also be of considerable interest to readers.

Sincerely,

Ricardo Santos de Oliveira, M.D, PhD.

Associate Professor & Chief of the Division of Neurosurgery Ribeirão Preto Medical School

University of Sao Paulo