Although previous studies have shown that altered B7 costimulation plays a critical role in UV irradiation-induced regulation of immunity, the individual roles of the B7 receptors (CD28 and CTLA-4) or the B7 family members (CD80 and CD86) have not been explored. Thus, we investigated CTLA-4 signaling during photocarcinogenesis of chronically UV-B-exposed mice using an antagonistic anti-CTLA-4 Ab. Anti-CTLA-4-treated mice developed significantly fewer UV-induced tumors. Moreover, anti-CTLA-4 treatment induced long-lasting protective immunity because progressively growing UV tumors inoculated into anti-CTLA-4- and UV-treated mice that had not developed tumors were rejected. Next, we used mice deficient for CD80, CD86, or both in photocarcinogenesis studies to assess the relative contributions of these CTLA-4 ligands. Double-deficient mice showed significantly reduced UV-induced skin tumor development, whereas CD86−/− mice produced skin cancer earlier compared with CD80−/− and control mice. The growth of UV-induced tumors appears to be controlled by UV-induced suppressor T cells, because CD80−/−/CD86−/− mice had strongly reduced numbers of UV-induced CD4+CD25+ suppressor T cells. In vitro, CTLA-4 blockade inhibited the suppressor activity of UV-induced CD4+CD25+ T cells, suggesting that reduced photocarcinogenesis might be due to decreased numbers or function of suppressor T cells. Together, these data indicate that blocking CD80/86-CTLA-4 signaling induced immune protection against the development of UV-induced skin tumors. Furthermore, CD86-mediated costimulation appears to play a more critical role in the protection against photocarcinogenesis than CD80.

The purpose of this study was to review our experience with a single case of mastoiditis associated with sigmoid sinus thrombosis and increased intracranial pressure, and to review the experience of others through prior publications. We reviewed a case of a 6-year-old boy with an acute otitis media and mastoiditis, with associated ipsilateral sigmoid sinus and contralateral distal transverse sinus thrombosis. Based on the literature and our own experience, we conclude that most children with dural sinus thrombosis from acute otitis media and mastoiditis, in the setting of increased intracranial pressure, attain a good neurological outcome with a conservative neurosurgical approach. The mainstay of treatment seems to be appropriate antibiotic coverage and anticoagulation. Surgeries such as external ventricular drain, serial lumbar punctures, intracranial pressure monitor, and endovascular thrombectomy are reserved for patients with neurological deterioration despite maximal medical treatment.

OBJECTIVEThe risk of venous thromboembolism (VTE) from deep venous thrombosis (DVT) is significant in neurosurgical patients. VTE is considered a leading cause of preventable hospital deaths and preventing DVT is a closely monitored quality metric, often tied to accreditation, hospital ratings, and reimbursement. Adult protocols include prophylaxis with anticoagulant medications. Children’s hospitals may adopt adult protocols, although the incidence of DVT and the risk or efficacy of treatment is not well defined. The incidence of DVT in children is likely less than in adults, although there is very little prospectively collected information. Most consider the risk of DVT to be extremely low in children 12 years of age or younger. However, this consideration is based on tradition and retrospective reviews of trauma databases. In this study, the authors prospectively evaluated pediatric patients undergoing a variety of elective neurosurgical procedures and performed Doppler ultrasound studies before and after surgery.METHODSA total of 100 patients were prospectively enrolled in this study. All of the patients were between the ages of 1 month and 12 years and were undergoing elective neurosurgical procedures. The 91 patients who completed the protocol received a bilateral lower-extremity Doppler ultrasound examination within 48 hours prior to surgery. Patients did not receive either medical or mechanical DVT prophylaxis during or after surgery. The ultrasound examination was repeated within 72 hours after surgery. An independent, board-certified radiologist evaluated all sonograms. We prospectively collected data, including potential risk factors, details of surgery, and details of the clinical course. All patients were followed clinically for at least 1 year.RESULTSThere was no clinical or ultrasound evidence of DVT or VTE in any of the 91 patients. There was no clinical evidence of VTE in the 9 patients who did not complete the protocol.CONCLUSIONSIn this prospective study, no DVTs were found in 91 patients evaluated by ultrasound and 9 patients followed clinically. While the study is underpowered to give a definitive incidence, the data suggest that the risk of DVT and VTE is very low in children undergoing elective neurosurgical procedures. Prophylactic protocols designed for adults may not apply to pediatric patients.Clinical trial registration no.: NCT02037607 (clinicaltrials.gov)

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The NICO Myriad is an effective tool that allows a safe minimally invasive endoscopic resection of craniopharyngiomas in patients with amenable anatomy. Surgeons with experience in neuroendoscopy may be able to achieve a gross total resection of these challenging tumors through a minimally invasive burr hole approach.

Low-grade fibromyxoid sarcoma (LGFMS) is a rare mesenchymal tumor that is characterized by a benign histology but potentially aggressive clinical behavior, with a high rate of recurrence and metastasis. It primarily occurs in young adults in the extremities, inguinal area, neck, or chest wall. There are rare reports of intracranial LGFMS in adults. In this report, the authors present the case of a 5-year-old girl who presented with a rapidly enlarging frontal scalp mass. Pathological examination of the resected mass demonstrated LGFMS. To the authors' knowledge, this is the only reported case of intracranial LGFMS in a child.

Practitioners should have a high index of suspicion for potential shunt contamination and CSFoma development in patients with Monti channels and a history of difficult catheterization.

We review the relevant embryology and suggest a possible mechanism for Chiari formation in this patient.