The effect of surgery for split spinal cord malformation on neurologic and urologic function

The split spinal cord malformation (SSCM) is an occult spinal dysraphism which causes tethering of the spinal cord. We performed a retrospective analysis of 15 patients who had split cord malformations (without associated open neural tube defect) who underwent both pre- and postoperative urodynamic studies (UDS) in order to determine if a significant percentage of these patients, even in the absence of overt urologic symptoms, had evidence of urologic dysfunction. Eleven patients presenting in early childhood and 4 patients presenting later in life are reviewed. Despite the lack of preoperative urologic symptoms in almost all patients, 73% of patients had voiding abnormalities on formal testing. UDS on these patients before and after surgery was a useful adjunct to perioperative management and decision making, helped define the success of surgery, and gave objective information for cases in which retethering was suspected.

Persistent high risk of diarrhea among foreigners in Nepal during the first 2 years of residence

Although numerous studies have shown that diarrhea is the most common illness occurring during the first few weeks of travel, systematic studies of the incidence of diarrhea during long-term residence in developing countries have not been performed. We conducted a cohort study of the incidence and etiology of diarrhea among 77 expatriate adults who had lived in Nepal for <2 years. Persons were followed prospectively for up to 1 year (mean, 9 months). The incidence of diarrhea during the surveillance period was 3.3 episodes of diarrhea per person per year, or 0.27 episodes per person per month. The annual attack rate of specific pathogens was 42% for enterotoxigenic Escherichia coli, 32% for Cyclospora species, 16% for Giardia lamblia, 16% for Shigella species, 10% for Campylobacter species, > or =10% for rotavirus, and 6% for Entamoeba histolytica. This study suggests that adult persons from developed countries who move to developing countries such as Nepal remain at high risk for diarrhea during their first 2 years of residence.

The socioeconomic impact of hepatitis E in Nepal

Hepatitis E disease is responsible for substantial morbidity in Nepal. A socioeconomic analysis was performed to describe the costs and the effects of hepatitis E disease (HE) on health status in a Nepalese population living in the Kathmandu Valley. A modified health status index was used to quantify healthy days lost associated with HE. One hundred thirty-four individuals recently recovered from HE were interviewed in June 1998. The median age was 22 years and 60% were female. Study participants were sick and bedridden for a median of 22 and 10 days, respectively. The median healthy days lost per individual was 35 (768,000 total per region). The median cost of illness per individual, including direct and indirect, was $37 ($1,238,676 total per region). The percentage of yearly income lost for wage earners totaled 19.4%. Hepatitis E disease is associated with significant costs and loss of healthy days in Nepal. Further research is warranted to understand and limit this common disease.

Cervicomedullary astrocytomas of childhood: clinical and imaging follow-up

BACKGROUND. Cervicomedullary astrocytomas are a unique subset of brainstem tumors in children because they have a good prognosis when compared to the pontine subset of brainstem gliomas. Objective. To review the clinical and imaging findings in a series of children with cervicomedullary astrocytomas as to diagnosis and management.

MATERIALS AND METHODS

A retrospective review of eleven children (six females, five males, age range: 10 days-18 years; mean = 7 years) with cervicomedullary tumors was done including the clinical presentation, imaging studies (MR: eleven, CT and MR: four), surgical findings, pathological results, and follow-up clinical and imaging findings (range: 0.2-11 years; mean = 5.2 years).

RESULTS

Symptoms and signs were delayed and protracted, often occurring over months to years (mean = 2.3 years, range 0.5-7 years). The tumors expanded the dorsal medulla and involved the upper cervical spinal cord (mean maximum tumor diameter = 4.4 cm). Only three patients had hydrocephalus. In three of four cases the tumor was not seen on CT. On MR, the majority of the tumors were T1 hypointense and T2 hyperintense. Treatment consisted of surgery only in six patients, surgery and radiation therapy in four, and surgery, chemotherapy, and radiation in one. There was recurrent local disease in four patients and on follow-up metastatic disease in the brain in one. On follow-up the majority of the patients are alive and stable (mean = 5.2 years, range 0.2-11 years). There has been one death. The majority of tumors were pilocytic astrocytomas.

CONCLUSION

Cervicomedullary tumors are a unique subset of brainstem gliomas in childhood that present with a long duration of symptoms and a greater long-term survival than pontine gliomas.

Management of cavernous malformations in the pediatric population

The management of cavernous malformations (CMs) in a child is similar in many ways to that of CMs in an adult. There are specific general principles that need to be considered when approaching these lesions in children, however. The long life span anticipated in the pediatric patient may favor an aggressive surgical approach for single, small asymptomatic cavernous malformations or for certain symptomatic lesions in eloquent locations. The observed history of a given malformation may be the best guide to determine its treatment. The authors discuss some of these principles and review their experience with a series of children who have presented for management of cerebral CM.

Spontaneous thrombosis of vein of Galen aneurysmal malformation

Two cases of aneurysmal malformations of the vein of Galen (AVG) with spontaneous thrombosis are reported. Angiogram and MRI before thrombosis demonstrated AVGs with slow arteriovenous shunts and associated stagnation of contrast in the venous sac secondary to severe outflow restriction. Based on these findings, one patient was managed conservatively, and the other underwent placement of a ventriculoperitoneal shunt. Surveillance of the lesions with subsequent MRIs revealed spontaneous thrombosis of the AVGs with excellent clinical outcomes. Proposed mechanisms of spontaneous thrombosis include slow flow shunts, obstruction of the venous outflow or obstruction of the feeding artery. Similar cases in the literature are reviewed with special emphasis on diagnostic tests, symptomatology, mechanisms of thrombosis and therapeutic options.

Analysis of posterior plagiocephaly: deformational versus synostotic

Appropriate management of posterior plagiocephaly requires differentiation of occipitoparietal flattening caused by lambdoid synostosis from that caused by deformational forces. In a 2 1/2-year prospective study of 115 infants presenting with unilateral posterior cranial flattening, only one child had synostotic posterior plagiocephaly (lambdoid synostosis), whereas 114 infants had deformational posterior plagiocephaly. Deformational occipitoparietal flattening was more common on the right (61 percent) than on the left (30 percent), and minor contralateral frontal flattening was not unusual (52 percent). The ipsilateral ear was anteriorly displaced in virtually all infants (97 percent). Some infants had ipsilateral torticollis (19 percent); a few had contralateral torticollis (8 percent). Gender ratio was 3:1, male:female. A total of 114 infants with deformational posterior plagiocephaly were treated conservatively either by head positioning in the crib (n = 63) or with a molding helmet (n = 51). Outcome was assessed by pretreatment and posttreatment anthropometry on 53 of these infants, who were either positioned (n = 17) or helmeted (n = 36). Improvement occurred in 52 of 53 patients (mean follow-up 4.6 months), i.e., the difference in length between the long and short transcranial axis diminished in 52 infants (mean 1.2 to 0.7 cm), did not progress in any child, and was unchanged in one infant. At an average age of 10 months, posterior cranial symmetry was better in infants treated with a helmet (mean difference 0.6 cm) than in those managed by positioning (mean difference 1.0 cm) (p < 0.001). Age at initiation of helmet therapy (from 2 to 9 months) was unrelated to rate of improvement. In a 10-year retrospective study, the authors identified 12 infants who had an operation for posterior plagiocephaly. All but one had confirmed premature lambdoid fusion; thus, this condition accounted for 3.4 percent of all primary operations performed for craniosynostosis during this decade (n = 323). In retrospect, the physical findings of synostotic posterior plagiocephaly were not clearly different from those of deformational posterior plagiocephaly. Plain radiography was sometimes used to confirm the clinical diagnosis. Neither sutural narrowing, deep interdigitations, nor perisutural sclerosis indicated lambdoid synostosis. Computed tomography (CT) was necessary if the physical findings were suspicious for lambdoid synostosis or if plain films did not give a definitive diagnosis. Axial CT scans (n = 7) showed a symmetric forehead in all but one patient with lambdoid synostosis. CT studies also demonstrated that auricular position was indeterminate in synostotic posterior plagiocephaly, being anterior, posterior, or symmetric, whereas the ipsilateral ear was virtually always anterior in deformational posterior plagiocephaly.

Moyamoya syndrome associated with cocaine abuse. Case report

The authors report the case of a 30-year-old woman who was a long-term intranasal cocaine abuser and who presented with transient ischemic attacks and multiple cerebral infarctions that were associated with moyamoya syndrome. The authors suggest that, because of its sympathomimetic effects, chronic cocaine use may promote intracranial arterial stenosis, distal ischemia, and subsequent formation of moyamoya-like vessels. The patient has remained clinically stable with no new episodes of stroke 6 years after undergoing "pial synangiosis" (modified encephaloduroarteriosynangiosis) to revascularize both hemispheres. Cocaine abuse may lead to moyamoya syndrome and may represent a chronic effect on the cerebral vasculature.

Neurologic complications of cerebral angiography in childhood moyamoya syndrome

Purpose. To determine the incidence of neurologic complications of cerebral angiography in children with moyamoya syndrome (MMS) as compared to children without MMS. Materials and methods. One-hundred-ninety consecutive cerebral angiograms obtained in 152 children were evaluated. Sixty of these angiograms were obtained in 40 children with MMS. Patients underwent neurologic evaluation prior to and after the procedure. For this study, a neurologic complication was defined as any new focal neurologic deficit or alteration in mental status occurring during the procedure or within the ensuing 24 hours. Results. There were 2 neurologic complications within 24 hours of angiography, one in the MMS group and one in the non-MMS group. One patient with MMS became mute following angiography. The symptom resolved within 12 hours. One patient without MMS being examined postoperatively for residual arteriovenous malformation developed intracranial hemorrhage requiring reexploration 12 hours after the angiogram. Using a two-tail Fisher's exact test, there was no significant statistical difference in the ischemic (P = 0.3) or hemorrhagic (P = 1.0) complication rates between the group of patients with MMS and the non-MMS groups. Conclusion. The risk of a neurologic complication from cerebral angiography in children with MMS is low and not statistically different from the risk in children with other cerebrovascular disorders.

Multilocus linkage identifies two new loci for a mendelian form of stroke, cerebral cavernous malformation, at 7p15-13 and 3q25.2-27

Cerebral cavernous malformation (CCM) is a Mendelian model of stroke, characterized by focal abnormalities in small intracranial blood vessels leading to hemorrhage and consequent strokes and/or seizures. A significant fraction of cases is inherited as an autosomal dominant trait with incomplete penetrance. Among Hispanic Americans, virtually all CCM is attributable to a founder mutation localized to 7q ( CCM1 ). Recent analysis of non-Hispanic Caucasian kindreds, however, has excluded linkage to 7q in some, indicating at least one additional CCM locus. We now report analysis of linkage in 20 non-Hispanic Caucasian kindreds with familial CCM. In addition to linkage to CCM1, analysis of linkage demonstrates linkage to two new loci, CCM2 at 7p13-15 and CCM3 at 3q25.2-27. Multilocus analysis yields a maximum lod score of 14.11, with 40% of kindreds linked to CCM1, 20% linked to CCM2 and 40% linked to CCM3, with highly significant evidence for linkage to three loci (linkage to three loci supported with an odds ratio of 2.6 x 10(5):1 over linkage to two loci and 1.6 x 10(9):1 over linkage to one locus). Multipoint analysis among families with high posterior probabilities of linkage to each locus refines the locations of CCM2 and CCM3 to approximately 22 cM intervals. Linkage to these three loci can account for inheritance of CCM in all kindreds studied. Significant locus-specific differences in penetrance are identified. These findings have implications for genetic testing of this disorder and represent an important step toward identification of the molecular basis of this disease.

Familial intracranial arteriovenous malformations. Case report and review of the literature

Familial intracranial arteriovenous malformations (AVMs) are rare. We describe a father and son both presenting in childhood with cerebral AVMs. Both patients underwent successful surgical extirpation of the AVM. Familial AVMs present at a young age and tend to be multiple, as was the case in one of our patients. Imaging of asymptomatic family members may detect previously undiagnosed AVMs, and we recommend screening of the relatives of patients with a strong family history of such lesions.

Papillary glioneuronal tumor: a new variant of mixed neuronal-glial neoplasm

We describe the clinicopathologic features of nine cases of a unique papillary glioneuronal tumor (PGNT) exhibiting astrocytic as well as extensive and varied neuronal differentiation. The four male and five female patients studied ranged in age from 11 to 52 years (mean 27.7 years). They either presented with mild neurologic symptoms or were asymptomatic. Magnetic resonance imaging showed demarcated cystic, 1.5-cm to 7-cm contrast-enhancing masses; five involved the temporal lobe, two the parietal, and two the frontal. All but one were totally resected. No recurrence was noted despite a follow-up period of 3 years. Two microscopic components were evident: 1) compact pseudopapillae composed of hyalinized vessels covered by a single layer of glial fibrillary acid protein (GFAP)-positive astrocytes and 2) synaptophysin-positive neuronal cells of varying size, including neurocytes, ganglioid cells, and ganglion cells within neuropil. Immunostains for chromogranin-A were negative, as was in situ hybridization for chromogranin-A mRNA. Ultrastructurally, neuronal cells featured microtubule-containing processes and aberrant synaptic terminals, but dense core granules were rare. Overall, cellularity was moderate and atypia was minimal. No mitotic activity or necrosis was noted. The proportions of the two components varied, but essential morphologic findings were identical in all cases. In that the clinical, radiographic, and morphologic characteristics of PGNT are distinctive, it appears to represent a previously undescribed form of mixed neuronal-glial tumor of the central nervous system.

Cerebral vasculopathy and neurologic sequelae in infants with cervicofacial hemangioma: report of eight patients

PURPOSE

To determine the association of cerebral arterial anomalies and progressive cerebral arterial occlusive disease in infants with facial hemangiomas.

MATERIALS AND METHODS

The cases of eight infants (seven girls and one boy) with the diagnosis of cervicofacial hemangioma and intracranial arterial anomalies were reviewed retrospectively. Findings from clinical and imaging examinations--including cranial computed tomography, magnetic resonance imaging and angiography, and catheter angiography--were evaluated. Serial imaging findings were studied to document progressive intracranial vascular changes.

RESULTS

Five patients had additional associated congenital anomalies. Seven were treated with corticosteroids, interferon alfa-2a, or both. Progressive cerebrovascular occlusive changes were documented in four of the seven patients with serial imaging findings. Four other patients (all treated pharmacologically) had MR imaging documentation of cerebral infarction, and all had consistent, acquired neurologic symptoms.

CONCLUSION

Intracranial arterial anomalies can coexist with cervicofacial hemangioma. Aneurysmal and occlusive changes are potentially progressive and can result in cerebral infarction. A causative association between occlusive cerebrovascular disease and pharmacologic treatment has not been excluded.

Focal cortical dysplasia with glioproliferative changes causing seizures: report of 3 cases

In contrast to neoplasia, lesions of focal cerebral dysplasia are thought to be completed developmental processes of abnormal neuronal migration. We present three children with seizures resulting from brain lesions which pathologically demonstrate regions of both clearcut focal cortical dysplasia and also hypercellularity and monomorphism typical of proliferative lesions such as low grade glial tumor. These cases suggest the existence of a distinct subgroup of patients with prominent glioproliferative changes in association with focal cortical dysplasia, challenging the conventional dichotomy between dysplastic and proliferative categories of brain lesions. Recognition of patients with dual pathology may be of practical as well as theoretical importance.

Surgical management of neonatal hydrocephalus

Maintenance of normal intracranial pressure is crucial to the development of the neonatal brain. Certainly, neonatal hydrocephalus will perturb cerebral development and calls for careful and timely intervention. Many competing factors must be taken into account when evaluating the neonate with hydrocephalus. A neurosurgical approach to the management of neonatal hydrocephalus is presented with emphasis on practical treatment paradigms.

The use of clinical practice guidelines (CPGs) to evaluate practice and control costs in ventriculoperitoneal shunt management

BACKGROUND

As a step toward maximizing the quality and cost-effectiveness of neurosurgical care, we designed clinical practice guidelines (CPGs) for the management of VP shunt malfunctions and infections at a tertiary care pediatric teaching institution. The detailed CPGs determine the use of radiographic studies, laboratory tests, and invasive procedures in the management of this problem. One purpose of the CPGs is to provide clear clinical guidelines for the medical trainee, thereby reducing variability in care and unnecessary utilization of resources.

METHODS

The CPGs were developed in stages over a 2-year period. The practice patterns in our institution for the management of shunt malfunctions and infections were articulated. They were compared with those published in the neurosurgical literature, and areas of clinical decision-making variability were identified. Preliminary guidelines were formulated, and data regarding patient care were prospectively collected. Based on this data, final CPGs were formulated and implemented. Total and itemized hospital charges for patients managed according to the CPGs were compared with those for patients in the 3 years before CPG implementation.

RESULTS

CPG-managed patients had generally lower total and itemized charges as compared with control patients. Decreased charges per hospital day and charges for shunt films in the CPG group were statistically significant.

CONCLUSIONS

The process by which the CPGs were developed and implemented, as well as the CPGs themselves, are described. We also present the clinical, demographic, and financial data that were prospectively collected for all patients managed within the CPGs over an initial 1-year period and compare it with data obtained for control groups of shunt malfunction patients admitted during the 3 years before implementation of the CPGs. We find a trend toward reduction of charges after implementation of the CPG.

Synostotic frontal plagiocephaly: anthropometric comparison of three techniques for surgical correction

Surgical correction of synostotic frontal plagiocephaly ("unilateral coronal synostosis") focuses on distortions of the forehead and orbits. Technical variations include unilateral versus bilateral fronto-orbital positioning. Surgical alignment of the deviated nasal root was introduced in our unit. Anthropometry was used to assess anatomic outcome, and results were compared in 22 children with synostotic frontal plagiocephaly who had either (1) unilateral fronto-orbital advancement ("canthal advancement") (n = 8), (2) bilateral fronto-orbital advancement/ modeling without nasal straightening (n = 7), or (3) bilateral fronto-orbital advancement/modeling with closing wedge nasal osteotomy (n = 7). Postoperative fronto-orbital asymmetry was most marked in the group I patients wherein the ipsilateral supraorbital rim was retruded 3.9 mm and elevated 2.6 mm, on average relative to the corneal apex, compared with the normal side. Group II children averaged 2-mm orbital retrusion and 2.2-mm elevation. Group III patients averaged 1.4-mm orbital retrusion and 2.9-mm elevation. These differences in orbital rim measurements among the three groups were not statistically significant. Postoperative nasal root angulation of 4 degrees or more was found in more than 50 percent of children who had either a unilateral or a bilateral procedure, without nasal correction. In contrast, primary nasal osteotomy resulted in a nasal cant of 3 degrees or less in all children. This difference in nasal angulation among the three groups was statistically significant (p = 0.035). Group III had a straighter nasal angle than groups II and I (in that order). Measurement of the distances from nasion to inner and to outer canthi also reflected persistent deviation of the nasal root. Group III children had a more central radix than either group I or II (p = 0.05). The data in this study support an operative strategy of bilateral (parallelogrammic) positioning of the forehead/ superior orbits with primary correction of nasal root angulation.

Childhood optic chiasm gliomas: radiographic response following radiotherapy and long-term clinical outcome

PURPOSE

In children with chiasmal gliomas, radiation therapy can arrest progressive visual and neurologic impairment. We examined the radiographic response and clinical outcomes after irradiation.

METHODS AND MATERIALS

Forty-two children (median age at diagnosis, 6.6 years) with chiasmal gliomas were managed as follows: 11 asymptomatic patients with neurofibromatosis-1 (NF-1) were observed only; 2 patients, less than 3 years old, underwent surgery and chemotherapy to delay irradiation; and 29 patients with progressive disease received radiation with or without prior surgery or chemotherapy. Time to radiographic response, long-term tumor control and late sequelae were reviewed for the 29 irradiated patients.

RESULTS

The probability of at least 50% radiographic response at 24 months after irradiation was 18.1% and increased to 38.2% by 48 months and 45.9% by 60 months. By actuarial analysis, the median time for such radiographic response was 62 months. For the 29 irradiated patients, the 10-year freedom from progression and overall survival rates were 100% and 89%, respectively (median follow-up for surviving patients, 108 months). Stabilization or improvement in vision occurred in 81% of 26 evaluable irradiated patients.

CONCLUSIONS

Notable radiographic response may be observed years after irradiation. Radiation therapy provides excellent long-term tumor control and vision preservation or improvement in the majority of patients with progressive chiasmal gliomas.