Objective To compare the evolution of motor function from mid‐gestation to 12 months of age between prenatally and postnatally repaired cases of open neural tube defect (ONTD). Methods This was a retrospective cohort study of all fetuses that underwent prenatal (fetoscopic or open hysterotomy) or postnatal ONTD repair at a single institution between November 2011 and December 2018. The anatomical level of the lesion was defined as the upper bony spinal defect at initial magnetic resonance imaging assessment. Prenatal motor function of the lower extremities was evaluated by ultrasound according to the metameric level of the neurological lesion, based on the methodology of Carreras et al. Fetal motor function was assessed at referral, at 6 weeks after surgery in prenatally repaired cases or 6 weeks after referral in postnatally repaired cases (6‐week follow‐up) and at the last scan before delivery. In addition, motor function was assessed by a detailed neurological examination at birth and 12 months of age. First sacral (S1) neurological level of the lesion was considered as intact motor function. For statistical comparisons, we attributed numerical scores to each neurological level and motor function was expressed as median (range) neurological level. Motor function (as numerical score) and the proportion of cases with intact motor function and with motor function two or more levels better than expected based on the anatomical level of the lesion were compared between the prenatal‐ and postnatal‐repair groups. Fetal motor function was compared to the anatomical level of the lesion at referral and a better motor function was defined when it was two or more levels better than the anatomical level of the lesion. To assess the evolution of motor function, we compared motor function at referral with that at each follow‐up assessment using paired t‐tests. Results We included 127 patients with ONTD, of whom 93 underwent prenatal (51 fetoscopic and 42 open hysterotomy) and 34 postnatal repair. At the time of referral, cases in the prenatal‐ and postnatal‐repair groups presented with a similar anatomical level of lesion (L3 (T9–S1) vs L3 (T7–S1); P = 0.52), similar motor function (S1 (L1–S1) vs S1 (L1–S1); P = 0.52) and a similar proportion of cases with intact motor function (81% vs 79%; P = 0.88) and with motor function two or more levels better than expected based on the anatomical level of the lesion (62% vs 74%; P = 0.24). When compared with prenatally repaired cases, postnatally repaired cases showed worse motor function at birth (S1 (L1–S1) vs L4 (L1–S1); P < 0.01) and at 12 months of age (S1 (L1–S1) vs L4 (L1–S1); P < 0.01). In the prenatal‐repair group, motor function remained stable from the time of referral to 12 months of age (P = 0.26). Furthermore, the proportion of patients with intact motor function at referral (81% (75/93)) was similar to that at the 6‐week follow‐up (74% (64/87)), at the last scan before birth (74% (42/57)), at birth (68% (63/93)) and at 12 months of age (67% (39/58)) in the pren...

CONTRIBUTIONWhat are the novel findings of this work? Prenatal and postnatal brain microstructure is similar between infants who underwent open hysterotomy and those who had fetoscopic spina bifida repair, and changes seen over time were also comparable between the two groups. These findings support the safety of using CO 2 gas for uterine insufflation during fetoscopic spina bifida repair. What are the clinical implications of this work?The findings of this study add to the body of evidence supporting the use of CO 2 for uterine insufflation in fetoscopic myelomeningocele repair. Fetoscopic techniques are safer for the mother and the fetus than is open repair. As a shift in practice towards fetoscopic repair is expected, evidence for the safety of CO 2 use is of critical relevance. ABSTRACTObjective To compare prenatal and postnatal brain microstructure between infants that underwent fetoscopic myelomeningocele (MMC) repair and those that had open-hysterotomy repair. Methods This was a longitudinal retrospective cohort study of 57 fetuses that met the Management of Myelomeningocele Study (MOMS) trial criteria and underwent prenatal MMC repair, by a fetoscopic (n = 27) or open-hysterotomy (n = 30) approach, atResults There were no differences in GA at surgery or GA/postnatal age at MRI between the groups. No significant differences were observed in ADC values in any of the brain areas assessed between the open-repair and fetoscopic-repair groups at 6 weeks after surgery and in the first year after birth. No differences were detected in the ADC values of the studied areas between the control 88 Sanz Cortes et al. and prenatally repaired groups, except for significantly increased ADC values in the genu of the corpus callosum in the open-hysterotomy and fetoscopic-repair groups. Additionally, there were no differences between the two prenatally repaired groups in the percentage change in ADC values at any of the time intervals analyzed. ConclusionsFetoscopic MMC repair has no detectable effect on brain microstructure when compared to babies repaired using an open-hysterotomy technique. CO 2 insufflation of the uterine cavity during fetoscopy does not seem to have any isolated deleterious effects on fetal brain microstructure.

OBJECTIVENumerous surgical procedures facilitate revascularization of the ischemic brain in patients with moyamoya disease. Dural inversion is a technique in which flaps of dura mater centered around the middle meningeal artery are inverted, encouraging the formation of a rich collateral blood supply. This procedure has been used in combination with encephaloduroarteriosynangiosis for more than 20 years at the authors’ institution for the treatment of pediatric moyamoya disease. The objective of this study was to describe the clinical and radiographic outcomes for a cohort of consecutive pediatric moyamoya patients undergoing dural inversion.METHODSClinical and radiographic data on patients who had undergone dural inversion in the period from 1997 to 2016 were reviewed. Univariate and multivariate logistic regression and Kaplan-Meier analyses were performed to assess the risk of postoperative stroke, functional outcome, and the angiographic degree of revascularization.RESULTSDural inversion was performed on 169 hemispheres in 102 patients. Median follow-up was 4.3 years. Six patients (3.6% of hemispheres) suffered postoperative ischemic or hemorrhagic stroke. Overall mortality was 1.0%. Good postoperative neurological status (modified Rankin Scale [mRS] score ≤ 2) was observed in 90 patients (88%); preoperative and postoperative mRS scores showed significant improvement (p < 0.001). Eighty-six percent of hemispheres had Matsushima grade A or B revascularization. Younger age was associated with postoperative stroke and poor functional outcome. Patients with secondary moyamoya syndrome had a significantly worse radiographic outcome. The cumulative 5-year Kaplan-Meier risk for stroke was 6.4%.CONCLUSIONSDural inversion is a useful technique of cerebral revascularization in pediatric moyamoya disease. A 20-year experience demonstrates the safety and efficacy of this technique with a relatively low rate of postoperative stroke, good functional outcomes, and favorable angiographic results.

Objective To identify predictors for intact motor function (MF) at birth and at 12 months of life in babies with prenatally versus postnatally repaired open spina bifida (OSB). Design Retrospective cohort study.

OBJECTIVEIntracranial arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children. Exploring outcomes of treatment and factors that predict recurrence may help guide the management of pediatric AVMs. In this study, the authors review a single-center experience with pediatric AVMs, aiming to identify factors contributing to recurrence and areas for improvement in treatment.METHODSA single-center retrospective review of patients ages 0–18 years with AVMs in the period from 2005 to 2018 was conducted. Demographic, clinical, and radiographic data were collected and examined to compare the clinical and functional outcomes of patients managed with and those managed without open microsurgical resection.RESULTSOne hundred five patients were diagnosed and treated during the study period. Fifty (47.6%) had been treated surgically and 35 (33.3%) nonsurgically, and 20 (19%) had been treated primarily at an outside institution and thus were excluded from further analysis. Of the 50 treated surgically, 92% had complete obliteration on postoperative imaging, with the remaining patients having residual AVM and undergoing re-resection or SRS, ultimately resulting in a 96% radiographic cure rate. The surgically treated patients were followed up for an average of 3.34 years. Eighty-two percent had a modified Rankin Scale (mRS) score of 0–2. There was a recurrence rate of 12%, with the time to recurrence averaging 327.86 days (range 85–596 days). Of the 35 patients managed without open surgery, 77% underwent serial imaging surveillance, 20% underwent endovascular embolization, and 3% underwent stereotactic radiosurgery. Radiographic cure was seen in 6% of those treated nonsurgically, and all had undergone endovascular treatment alone. The nonsurgically treated patients were followed up for an average of 2.14 years. Eighty percent had an mRS score of 0–2.CONCLUSIONSThe data revealed that patients with lower-grade AVMs treated surgically and those with higher-grade AVMs managed without surgery have good functional and clinical outcomes. A high rate of recurrence was noted, and the possible contributing factors were explored. The authors encourage further study into mechanisms to reduce AVM recurrence in pediatric patients and look forward to advances in the medical management of lesions that are considered unresectable.

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the fetus to measure pulsatility index (PI), resistive index (RI), and peak systolic velocity (PSV). We compared each measurement between donors and controls, and recipients and controls. Inter-twin ratios of the PI, RI, and PSV were compared between TTTS cases and MCDA controls. Lastly, we performed a subgroup analysis involving pregnancies with TTTS that underwent fetoscopic laser therapy and resulted in twin survivors in order to evaluate if laser therapy influenced RAD findings. RESULTS: We recruited 12 cases and 12 controls. Between TTTS donors and controls, there was no difference in RAD PI (median ¼ 1.27 [1.14-1.49] vs. median ¼ 1.49 [1.30-1.66], p¼0.12) or RAD RI (median¼ 0.74 [0.70-0.87] vs. median ¼ 0.82 [0.77-0.83], p¼0.19). TTTS donor RAD PSV was significantly lower than that of controls (median ¼ 14.24 [11.51-15.36] vs. median ¼ 24.79 [22.46-27.03], p<0.0004). There was no difference in RAD PI, RI, and PSV between TTTS recipient twins and controls. RAD PSV inter-twin ratios were significantly higher among twin pairs with TTTS (median ¼ 1.70 [1.53-2.02]) when compared to controls (median ¼ 1.06 [1.03-1.15]), p¼0.002. Applying a RAD PSV ratio cutoff of greater than 1.35 for the diagnosis of TTTS, 11/12 cases with TTTS and all 12/12 controls without TTTS were correctly classified (92% sensitivity, 100% specificity). Among TTTS cases with double survivors after undergoing laser therapy (n¼4), pre-laser RAD PSV ratios (M¼1.46, SD¼0.37) were higher than post-laser RAD PSV ratios (M¼0.87, SD¼0.37), p¼0.02. Post-laser inter-twin RAD PSV ratios were similar to those among matched control twin pairs, p¼0.125. CONCLUSION: RAD PSV ratios differed between MCDA twins complicated by TTTS and those without TTTS. This effect was driven by altered donor twin RAD PSV values. Laser therapy may normalize RAD PSV ratios and donor twin RAD values to those observed in MCDA twins without TTTS. Further study should explore the utility of RAD PSV as a tool for TTTS prediction, diagnosis, staging, as well as for the evaluation of fetal response to laser therapy.