Research Shows Endoscopic Strip Craniectomy is Strong Alternative to Open Approaches for Craniosynostosis

Minimally invasive endoscopic strip craniectomy offers a strong alternative for infants with craniosynostosis, according to a growing body of research in pediatric neurosurgery.

“The data has been clear that this is a very effective surgery with excellent results, and it’s less invasive than the traditional open approaches for treating craniosynostosis,” says Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute. “A lot of the research that we and other groups have done shows that results are either as good or can even be better in certain aspects of facial growth compared to open vault reconstruction.”

Dr. Suresh Magge
Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute.

Dr. Magge’s research on the topic has included:

Traditional surgery for craniosynostosis is an open cranial vault reconstruction, in which a surgical team takes apart the skull in order to reshape the skull plates. If craniosynostosis is diagnosed early enough – preferably before four months of age – minimally invasive endoscopic surgery can correct this condition. Small incisions are made and, using a camera, the fused portions of the skull are removed.

While both the traditional cranial vault reconstruction and the minimally invasive surgery can offer excellent surgical results, the minimally invasive approach generally involves less blood loss and swelling, smaller incisions, reduced need for blood transfusions, less time under anesthesia and shorter hospital stays. Pediatric patients usually go home the day after surgery. Once surgery is completed, the patient is fitted for a cranial molding helmet he or she must wear for a few months that helps guide the skull correction over time.

“We have an outstanding craniofacial team, including neurosurgeons, plastic surgeons and maxillofacial surgeons, here at CHOC, and we strive to offer an individualized approach to each patient,” Dr. Magge says. “Physicians need to know that craniosynostosis requires an early diagnosis so that parents have the option of the minimally invasive surgery. At the same time, we want to give parents different options when it comes to surgery.”

Dr. Magge recently joined CHOC after an 11-year tenure as a pediatric neurosurgeon at Children’s National Hospital in Washington, D.C., where he started the medical center’s minimally invasive craniosynostosis program and was the director of neurosurgery fellowship training. He completed his neurosurgery residency training at the University of Pennsylvania and his pediatric neurosurgery fellowship training at Boston Children’s Hospital.

While Dr. Magge has a wide-ranging clinical practice, his special clinical and research interests include craniosynostosis, brain and spinal tumors, especially diffuse intrinsic pontine gliomas, and pediatric neurovascular disease, including arteriovenous malformation and Moyamoya disease. In his new role at CHOC, Dr. Magge looks forward to contributing to the growth of CHOC’s neurosurgical programs, including the brain tumor program, neurovascular program, epilepsy program, robotic surgeries and more. 

“It’s such an exciting time here at CHOC, from how we’re building and growing our programs to driving clinical innovation, as well as training the next generation of pediatric neurosurgeons through our affiliation with the University of California, Irvine,” Dr. Magge says. “We’re always asking ourselves, ‘What’s the best thing we can do for each child in the least invasive manner with the least amount of pain?’ and then doing so in a compassionate manner.”

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the neurology/neurosurgery specialty.

USNWR Neurology and Neurosurgery award

Learn how CHOC’s neuroscience expertise, coordinated care, innovative programs and specialized treatments preserve childhood for children in Orange County, Calif., and beyond.

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MRI-Guided Laser Ablation with Stereotactic Assistance Targets Epilepsy, Tumors

Laser interstitial thermal therapy (LITT), or laser ablation, is among the latest advancements in minimally invasive neurosurgery, allowing surgeons to reach difficult areas of the brain — and offering less risk to patients at the same time.

“Instead of performing a craniotomy, which entails making a large incision and opening up the skull, we place a probe through a small hole in the skull a few millimeters in diameter,” says Dr. Joffre Olaya, pediatric neurosurgeon at CHOC. “Then, under MRI visualization, we deliver heat to the specific area, which destroys the abnormal tissue. Laser ablation is especially useful in patients with small seizure foci or tumors, particularly if they are deep.”

Dr. Joffre Olaya, pediatric neurosurgeon at CHOC

The benefits this minimally invasive approach provides to patients are especially welcoming. “For a craniotomy, patients will be in the hospital for three to five days, in the ICU most likely for a day or two, and they’ll experience discomfort from the skin and muscles on the head,” Dr. Olaya says. “With laser ablation, patients typically go home within a day or two and recover pretty quickly. They also experience less blood loss, pain and side effects overall. Also, laser ablation doesn’t prevent patients from having another procedure. If the tumor is still growing or the seizures are still continuing after ablation, I can go back and perform another laser ablation or a craniotomy.”

To increase surgical precision and accuracy when ablating brain tumors, deep lesions and tissue in the brain where seizures occur, Dr. Olaya employs a ROSA™ (robotic stereotactic assistance) robot.

“We obtain preoperative imaging studies and load those into the ROSA system, which allows us to plan the entry point and trajectory so we can precisely place the laser. This precision helps us to not only locate and effectively ablate our target, but avoid hitting blood vessels or causing unintended damage to surrounding tissues,” Dr. Olaya says. “We were the first pediatric center on the West Coast to have this technology. We use ROSA for multiple conditions, including patients with epilepsy and oncology patients with tumors.”

ROSA’s precision also helps minimize some risks commonly associated with surgery. “ROSA is an amazing tool that yields many benefits for our patients, including less time under anesthesia in the operating room,” Dr. Olaya says. “It also reduces blood loss and risk of infections.”

Although CHOC is at the forefront utilizing the latest technologies to best treat its patients in a minimally invasive manner when possible, Dr. Olaya says CHOC’s team approach to patient care is what sets it apart from other centers in the region.

“I’m really excited that CHOC is investing in this newer technology and it’s available here to provide to our patients, but our team mentality and how well we work together is crucial. Our epileptologists, radiologists, neuropsychologists, all of us really work well together as a team to identify the best candidates for this technology and to provide the best outcomes for our patients.”

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the neurology/neurosurgery specialty.

Learn how CHOC’s neuroscience expertise, coordinated care, innovative programs and specialized treatments preserve childhood for children in Orange County, Calif., and beyond.

Years in the works, NICU hires its first senior fellow in neonatal cardiac intensive care

After years of planning, CHOC’s neonatal intensive care unit (NICU), in a partnership with UC Irvine Health, has hired its first senior fellow in neonatal cardiovascular ICU and hemodynamics – how the heart and blood vessels work together.

The fourth-year fellowship position is one of only two such ones in the western U.S. and the first-ever senior level fellowship at CHOC in any specialty, said Dr. Amir Ashrafi, a cardiac-neonatologist at CHOC and fellowship program director.

“It’s a really big deal,” he said. “We’re really establishing our excellence in this field.”

Neonatal cardiac intensive care is a newly emerging subspecialty within neonatology whose primary goal is to enhance the cardiovascular care of newborns with structural heart disease and/or hemodynamic instability.

“Medical information is increasing at such a fast rate, we are at the point where doctors need to sub-sub specialize,” Dr. Ashrafi said. “Here in CHOC’s NICU, we don’t only have neonatal intensive care doctors, but also we have neonatal cardiac intensive care doctors.”

A senior fellowship is one granted to a sub-sub specialist, and such positions are typically reserved for the most elite programs in the country, Dr. Ashrafi said.

“With this fellowship, we’ll start training the future generation of highly sub-specialized doctors who will practice state-of-the-art care for the sickest babies in the hospital,” Dr. Ashrafi said.

Following a selection process in which young neonatal intensive care physicians from around the world applied, the fourth-year fellowship position in Neonatal Cardiovascular ICU & Hemodynamic has been awarded to Southern California native Dr. Ziad Alhassen, 33, who currently is in the Neonatal-Perinatal medicine fellowship program at UC Davis Medical Center in Sacramento.

Dr. Ziad Alhassen

“I’m definitely excited and feel blessed to have the opportunity to work with world-class physicians at CHOC and to learn as much as I can from them,” said Ziad, whose fellowship begins July 1, 2021.

Dr. Anjan Batra, vice chair of the UC Irvine School of Medicine’s Department of Pediatrics, joins Dr. Ashrafi as associate director of the fellowship. The other two associate program directors are Dr. John Cleary, associate director of the neonatal-cardiac ICU at CHOC, and Dr. Wyman Lai, assistant division chief of cardiology, co-director of the cardiac institute, and director of the echocardiography lab at CHOC.

Ziad, who is married with two young children, grew up in West Covina. He received his medical education at the Royal College of Surgeons in Ireland, Bahrain (RCSI-Bahrain) and has been licensed with the American Board of Pediatrics since October 2018.

Ziad said he’s excited to serve CHOC’s patient population and is especially eager to improve his understanding of CHOC’s extracorporeal membrane oxygenation (ECMO) program, a heart and lung bypass machine reserved for babies with complete failure of their cardio-respiratory system. Part of Ziad’s responsibilities as a senior fellow will be managing all ECMO cases in the NICU.

“Neonatal-cardiac intensive care is something I’ve always wanted to do,” Ziad said. “During my residency, I found myself gravitating toward patients who were critically unstable and required intensive care. It is eternally rewarding to see them get better.”

Ziad’s father is a physician who specializes in general surgery. Ziad has five siblings and he is the second among them to become a practicing physician.

To learn more about CHOC’s NICU, click here.

Collaborative effort involving milestone procedure saves premature baby with complex heart disease

Baby Hope looked into her mother’s eyes and gurgled.

Four days short of turning 9 months old, wearing a white onesie with the words “Best Gift Ever” on the front, she made more baby talk.

“You’re always a big chatterbox – what are you saying?” her mother, Elizabeth “Becca” Wyneken, said as she smiled and stared into Hope’s blue eyes.

Becca and Hope endured a lot to get to where they are now — a happy and very grateful mom and a relatively healthy 9-month-old baby girl whose light-brown hair is just starting to fill in.

The odds were stacked against Hope when she was born prematurely at 31 weeks and five days, weighing just 2 pounds, 3 ounces. Today, Hope is alive thanks to a team of doctors, nurses and others who cared for her throughout a four month stay on CHOC’s neonatal intensive care unit (NICU) and cardiovascular intensive care unit (CVICU).

Born with a complex heart disease, as well as only one kidney and defects on her right leg and foot, Hope’s cardiac neonatologist, Dr. Amir Ashrafi, pegged her chances of survival at between 20 and 30%.

When Becca first set eyes on Hope a couple of days after she was born, she was very concerned about her baby’s health.

“Don’t worry, Mom,” Dr. Ashrafi told Becca that day. “I think we can help her.”

It would take an extensive collaboration between highly regarded cardiovascular interventionalists, some of whom were consulted at hospitals as far away as London, to do so.

And it would involve a high-risk procedure never performed on a baby so small at CHOC.

Dr. Amir Ashrafi, neonatologist at CHOC

Grim news at 20-week scan

At 18 weeks pregnant, Becca, a teacher’s aide, went in for a checkup. Blood tests showed her baby had a high risk for Down syndrome and spina bifida.

Two weeks later, a scan of her baby’s anatomy revealed other potential problems.

Her baby had no kidneys, Becca was told. She appeared to have no bladder, no right leg, no lungs, issues with her bowels, and a heart defect.

“I don’t think I stopped crying for the rest of the day,” Becca recalls. “It was horrible.”

She couldn’t drive home from the clinic. A friend had to pick her up. That night, Becca had dinner with her mother and aunt.

Later, lying beside her mother, Becca cried.

“I can’t believe this is happening,” she said.

She felt a poke in her belly.

“Over and over again, when I got upset, she would poke me,” Becca said.

At that moment, she decided on a name for her baby.

“Hope,” Becca told her mother.

Second opinion reveals true complications

Becca got a second opinion about her unborn baby’s condition.

Her baby was missing a kidney and had a leg defect, she was told. Most seriously, Becca was told, she had a defect on her right ventricle, the chamber within the heart responsible for pumping oxygen-depleted blood to the lungs.

Hope’s aorta and pulmonary artery that carry blood away from the heart hadn’t developed properly. She had a hole in her heart as well as one in her left superior vena cava, a vein that helps circulate deoxygenated blood back to the heart. These holes caused blood to drain incorrectly; Hope would need a team of doctors to correct the blood flow.

“Being very small with complex heart disease, your options are very limited with what you can do and the timing of any procedures,” said Dr. Ahmad Ellini, Hope’s primary pediatric cardiologist.

There were lots of sleepless nights as Hope’s team of doctors and nurses monitored her closely. Becca was beside her nearly every night.

Dr. Ashrafi and Dr. Ellini consulted with two outside experts, San Francisco-based Dr. Mohan Reddy, who specializes in complex heart disease in small newborns, as well as renowned thoracic and cardiac surgeon Dr. Glen Van Arsdell of Ronald Reagan UCLA Medical Center on the best course of action.

The team of physicians determined that a stent needed to be inserted under a pulmonary artery that was becoming too narrow, making it hard for blood to flow through it. Such a procedure is risky, especially on a baby so small.

“In Hope’s case, the idea was if we could open up the area below the valve while not injuring the valve, that would be a home run,” said Dr. Sanjay Sinha, a CHOC pediatric cardiologist who put the stent in Hope’s heart. “Two things made this difficult: she was very small, and we had no stents this size.”

A vendor was able to secure the small stent needed a day before Hope’s surgery.

Assisting Dr. Sinha during the procedure was Dr. Michael Recto, medical director of CHOC’s Cardiac Catheterization Lab.

Observing the recently developed procedure, known as valve-sparing RVOT (right ventricular outflow tract) stent placement, were several cardiologists, from CHOC and other pediatric hospitals.

“In some patients, there is very little room for a stent. Hope had just enough room for the stent to be placed,” Dr. Sinha explained, “We knew we had the technical skills and ability to do this, but this had never been done before at CHOC on a baby this size.”

A very scary moment

After the surgery, Hope got seriously ill with a viral infection. At one point, Dr. Ashrafi said, her heart stopped but the team was able to revive her.

In cases like Hope’s, where a newborn’s state of health is fragile, members of her clinical team often must pivot in an instant, making their work schedules long and unpredictable.

Hope was at CHOC for four months before she was able to go home. After that, physicians at another hospital removed the stent, closed the hole in her heart, and corrected her left superior vena cava.

Dr. Ellini, who continues to see Hope at her check-ups, is very pleased with her progress.

“She basically has a normal circulation,” he said. “She needed a pacemaker. Overall, she’s doing great. She’s only on one medication and is gaining weight.”

In fact, she’s up to 13 pounds.

Baby Hope

Dr. Ellini said he’s proud of the extensive collaboration that was involved in Hope’s care at CHOC.

“We try to really foster a collaborative team approach in our interventional lab, and this is a great example of that,” he said. “Having a dedicated neonatal cardiac intensive team of physicians and nurses who are really experts in what they do really was paramount in making sure she did well.”

Becca can’t praise Hope’s team at CHOC enough. “They’re totally lifesavers,” she said. “It was a roller coaster — heartbreaking and exiting. I was pretty much afraid all the time, but they treat you like you are family.”

Multi-Focus Seizures Complicate Surgical Treatment for Pediatric Epilepsy Case

During Celeste’s pregnancy, an ultrasound showed that her baby had heart abnormalities. Once baby Jaylynn was born, further diagnostic evaluation confirmed she had tuberous sclerosis complex (TSC), a disorder that causes growths in multiple organs, including the heart, brain, kidneys and lungs. TSC is a genetic disorder, and patients with this condition are known to have a high seizure burden.

In the days after her birth, the right side of Jaylynn’s body seemed to twitch, and Celeste’s instincts told her Jaylynn was having seizures. Celeste mentioned this to her nurse at the hospital where Jaylynn was born, but her worries were dismissed. After being sent home, Celeste called CHOC and met with Dr. Lily Tran, a pediatric epileptologist at CHOC’s level 4 pediatric epilepsy center.

Over the next three years, Jaylynn tried several different treatment options, including medications, ketogenic diet and steroid treatment. Most treatments followed the same pattern: the seizures would stop for a few months, but then come back stronger than before. She regressed significantly in terms of development, no longer made eye contact, could not sit up even with support and was lethargic all day due to the high seizure burden. She started losing weight and had to have a G-tube placed for adequate nutrition. Her medication regimen was at high doses to control seizures, which led to side effects, such as vomiting and lethargy, which impacted her quality of life significantly. Her days consisted of seizures, vomiting and sleep. At that point, Celeste said her family was simply trying to survive.

“Jaylynn’s refractory case of epilepsy was quite complex because we couldn’t pinpoint where her seizures were coming from based on Phase I surface EEG monitoring,” says Dr. Tran. “We used several different imaging techniques to locate the focus of her seizures, including a virtual reality simulation program. Through these tests and Phase II invasive EEG monitoring, we found her seizures were coming from the left side of her brain, but on this one side, we then found the seizures were coming from three distinct areas. Her case was discussed extensively at our comprehensive epilepsy surgery conference, but there was no clear-cut answer and consensus on what to do next. Each approach had various pros and cons, and each option had questions and concerns. As a team, we constantly asked ourselves, ‘What’s best for Jaylynn?’ when considering these treatment options. Mom was updated at every step of the way so she could make the most informed decision for her daughter.”

Because the seizure focus came from three different areas in the left hemisphere, it was not reasonable to resect these regions separately without significantly more post-operative side effects. Dr. Tran elected to proceed with a functional hemispherectomy to give Jaylynn the best outcome for seizure control and to turn her quality of life around. The procedure essentially “quieted down” the electrical activity in the left side of her brain.

“For Jaylynn, I used everything I learned in fellowship, consulted with other colleagues and leveraged the tools we have at CHOC — such as our ability to perform invasive surgery and our research capabilities — to determine the best course of treatment for this complex epilepsy case. When you have a multidisciplinary team like ours that includes a dedicated neurosurgeon, neuroradiologists, neuropsychologists, educated nurses, EEG technologists, epilepsy pharmacists, social workers and parent champions who work cohesively together, it helps make the patient’s journey a little bit easier.”

Today, Jaylynn is seizure-free and on fewer medications. She is now laughing and smiling, more interactive, enrolled in school and even got to visit Disney World.

“What makes CHOC different from similar centers, I think, is our focus on the patient journey and how we value the quality of life for each patient,” says Dr. Tran. “We treat every child and their family as a whole unit. When you come to CHOC, you’re not just our patient. You truly become part of our family.”

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the neurology/neurosurgery specialty.

Learn how CHOC’s neuroscience expertise, coordinated care, innovative programs and specialized treatments preserve childhood for children in Orange County, Calif., and beyond.