Upper limb motor function in young adults with spina bifida and hydrocephalus

OBJECTIVE

The objective of the study was to measure upper limb motor function in young adults with spina bifida meningomyelocele (SBM) and typically developing age peers.

METHOD

Participants were 26 young adults with SBM, with a Verbal or Performance IQ score of at least 70 on the Wechsler scales, and 27 age- and gender-matched controls. Four upper limb motor function tasks were performed under four different visual and cognitive challenge conditions. Motor independence was assessed by questionnaire.

RESULTS

Fewer SBM than control participants obtained perfect posture and rebound scores. The SBM group performed less accurately and was more disrupted by cognitive challenge than controls on limb dysmetria tasks. The SBM group was slower than controls on the diadochokinesis task. Adaptive motor independence was related to one upper limb motor task, arm posture, and upper rather than lower spinal lesions were associated with less motor independence.

CONCLUSIONS

Young adults with SBM have significant limitations in upper limb function and are more disrupted by some challenges while performing upper limb motor tasks. Within the group of young adults with SBM, upper spinal lesions compromise motor independence more than lower spinal lesions.

Spontaneous intraparenchymal hemorrhage in full-term neonates

OBJECTIVE

Spontaneous intraparenchymal hemorrhage is extremely rare in full-term newborns. Reports to date have been limited to descriptions of individual cases, small groups within larger studies of intracranial hemorrhage, and one series of four patients. Structural lesions are rarely identified, and the majority of patients described have been managed without surgical intervention.

METHODS

Analysis of a computerized database of pediatric neurosurgical patients from January 1960 to February 2000 identified full-term newborns younger than 3 months of age with nontraumatic intraparenchymal hemorrhages. Prenatal histories, labor and delivery histories, clinical presentations, imaging studies, management, and outcomes were reviewed.

RESULTS

Eleven full-term newborns with spontaneous intraparenchymal hemorrhages were identified. The majority had normal prenatal courses. Most presented within the first 2 days of life (6 of 11 patients), and the most common presenting sign was seizure (7 of 11 patients). No cause was identified in 6 of 11 patients; the remainder were attributed to coagulopathy (n = 3), ruptured intracranial aneurysm (n = 1), or hemorrhagic infarction (n = 1). Eight patients underwent surgical hematoma evacuation on the basis of radiographic evidence of significant mass effect, evidence of signs of elevated intracranial pressure, or both. Three patients did not receive surgical intervention. There were no subsequent hemorrhages or deaths during a mean follow-up period of 4.5 years (range, 1-16 yr). Four patients had normal neurological outcomes, four had motor deficits (one of whom additionally demonstrated cognitive delay), and three had delayed speech.

CONCLUSION

No cause is identified in most newborns with spontaneous intraparenchymal hemorrhage. Radiographic evidence of mass effect or signs of elevated intracranial pressure may necessitate surgical hematoma evacuation. Outcome varies widely and may be normal, even in patients with sizeable intraparenchymal hemorrhages.

Cerebellar arteriovenous malformations in children

We review the presentation, imaging findings and outcome in 18 children with cerebellar arteriovenous malformations (AVM). This group is of particular interest because of the reported poor outcome despite modern imaging and neurosurgical techniques. All children had CT and 15 underwent catheter angiography at presentation. Several of the children in the latter part of the study had MRI. Of the 18 children, 17 presented with a ruptured AVM producing intracranial haemorrhage. The remaining child presented with temporal lobe epilepsy and was shown to have temporal, vermian and cerebellar hemisphere AVM. This child had other stigmata of Osler-Weber-Rendu syndrome. Three other children had pre-existing abnormalities of possible relevance. One had a vascular malformation of the cheek and mandible, one a documented chromosomal abnormality and another a midline cleft upper lip and palate. Six of the 17 children with a ruptured cerebellar AVM died within 7 days of the ictus. Vascular pathology other than an AVM was found in 10 of the 14 children with a ruptured cerebellar AVM who had angiography: 4 intranidal aneurysms, 5 venous aneurysms and 2 cases of venous outflow obstruction (one child having both an aneurysm and obstruction). The severity of clinical presentation was directly related to the size of the acute haematoma, which was a reasonable predictor of outcome.

How children with head injury represent real and deceptive emotion in short narratives

Narratives are not only about events, but also about the emotions those events elicit. Understanding a narrative involves not just the affective valence of implied emotional states, but the formation of an explicit mental representation of those states. In turn, this representation provides a mechanism that particularizes emotion and modulates its display, which then allows emotional expression to be modified according to particular contexts. This includes understanding that a character may feel an emotion but inhibit its display or even express a deceptive emotion. We studied how 59 school-aged children with head injury and 87 normally-developing age-matched controls understand real and deceptive emotions in brief narratives. Children with head injury showed less sensitivity than controls to how emotions are expressed in narratives. While they understood the real emotions in the text, and could recall what provoked the emotion and the reason for concealing it, they were less able than controls to identify deceptive emotions. Within the head injury group, factors such as an earlier age at head injury and frontal lobe contusions were associated with poor understanding of deceptive emotions. The results are discussed in terms of the distinction between emotions as felt and emotions as a cognitive framework for understanding other people's actions and mental states. We conclude that children with head injury understand emotional communication, the spontaneous externalization of real affect, but not emotive communication, the conscious, strategic modification of affective signals to influence others through deceptive facial expressions.

Management and outcomes of posterior fossa subdural hematomas in neonates

OBJECTIVE

To review and analyze a contemporary series of 15 neonates who were treated for posterior fossa subdural hematomas (PFSDHs) during the era of computed tomography and magnetic resonance imaging.

METHODS

A retrospective chart review identified all neonates with PFSDHs for whom neurosurgical consultations were obtained for treatment planning.

RESULTS

There were nine male and six female patients. The mean gestational age was 39 weeks. Nine of the 15 mothers of the patients were primiparous. Instrument-assisted delivery (forceps and/or vacuum extractor) was undertaken for seven patients. The mean birth weight of the infants was 3165 g (range, 2160-3930 g). The mean 5-minute Apgar score was 7.5. Symptoms of PFSDH developed within the first 24 hours of life in 13 neonates. The predominant symptoms and signs were failure to thrive, irritability, seizures, apnea, and bradycardia. Lumbar punctures to rule out central nervous system sepsis were performed in six neonates. Hemograms revealed that six neonates were anemic with low hemoglobins, five had low platelets, and four had abnormal prothrombin and/or partial thromboplastin times at the time of diagnosis. Computed tomography established the diagnosis of PFSDH in all cases. Magnetic resonance imaging was performed for two neonates. The median time to diagnosis by imaging studies was 10 hours after birth. Surgical evacuation of the PFSDHs was performed in eight neonates. Seven neonates were followed conservatively with serial imaging studies. There was no mortality in either treatment group. Follow-up ranged from 2 to 10 years, with a mean of 4.5 years. Functional outcome assessment revealed that seven neonates were neurodevelopmentally normal, three were mildly delayed, two were moderately delayed, and three were profoundly delayed. In addition to traumatic causes of the PFSDHs, three neonates were observed to have coagulation disturbances at birth and one was observed at follow-up to have a posterior fossa medulloblastoma that had bled at birth.

CONCLUSION

PFSDHs are rare but important lesions to diagnose early in the neonatal period. Surgery can be life-saving when performed in a timely manner for signs and symptoms of brain stem dysfunction. A search for an underlying cause predisposing to a PFSDH may, on occasion, reveal a coagulation disturbance or a neoplasm that will require additional therapeutic considerations.

Long-term survival of an infant with 'anaplastic' astrocytoma

Anaplastic astrocytomas are intermediate in differentiation between astrocytoma and glioblastoma multiforme. Survival with anaplastic astrocytoma is favorably affected by extensive anaplasia, maximal resection and presentation in early life. We report a 2-month-old infant who had a tumor of astrocytic lineage with anaplastic features of necrosis, nuclear atypia and mitotic activity. Following subtotal resection the child is alive but has a radiologically visible tumor.

Choices in the 1990s for the management of pediatric cerebral arteriovenous malformations

A retrospective 45-year analysis of the management of 160 children with intracranial arteriovenous malformations at The Hospital for Sick Children, Toronto, reveals substantially improving outcomes which relate to more efficient diagnoses and treatments. 80% of children will declare their malformation by means of spontaneous intracranial hemorrhage. For those children who present with hemorrhage or epilepsy, 80% will require an operation. The overall mortality rate has declined to 12% since 1975 and that for the cerebellar lesions from 67 to 42%. 53% of the patients operated upon will be neurologically normal. Endovascular embolization of a child's AVM is a customized, partial solution for a limited number of children. Stereotactic radiosurgery will be used increasingly to obliterate those small lesions in children which are unassociated with hemorrhage or are the residua of an operation. As many as 10% of children (15/160) with diagnosed AVMs cannot be helped with operative or other interventional therapies. The recognition of the pediatric stroke syndromes, the early triage and diagnosis of a child's cerebral hemorrhage, the operative and anaesthetic technologies and the adjunct therapies - choices of the nineties - have resulted in a 66% decline in the overall mortality from this vascular lesion as well as greater assuredness that for most the lesion can be permanently obliterated.

Supratentorial primitive neuroectodermal tumors in children

A retrospective review of 36 children diagnosed with a supratentorial primitive neuroectodermal tumor (PNET) at the Hospital for Sick Children was performed for the period 1970-1995. All children but one received their initial treatment at our institution. There were 18 males and 18 females and the median age at diagnosis was 35 months. Twenty-two PNETs were lobar, 3 were deep in the hemisphere, and 10 were located in the pineal region. One child presented with intracranial leptomeningeal disseminated disease. The tumors were mostly undifferentiated although 22 had some evidence of differentiation along one or more neuroepithelial lines. Five children had a biopsy, 24 had subtotal resection, and 7 had gross total resection. Twenty-six children had adjuvant radiotherapy and 13 had chemotherapy. At last follow-up 30 patients were dead and 6 were alive. The median survival was 23 months and the 2, 3, and 5 year survivals were 50%, 34%, and 18% respectively. All of the survivors received craniospinal radiation and 4 received chemotherapy. There was a statistically significantly worse survival in young children. There was a trend to better survival in children treated since 1984, and in children undergoing gross total resection. Because of the extremely poor survival, we recommended that all children undergo gross total resection followed by chemotherapy. For children older than 3 years of age craniospinal radiation should also be given.

The detection and management of intracranial hypertension after initial suture release and decompression for craniofacial dysostosis syndromes

We performed a retrospective study of 107 consecutive patients with syndromic forms of craniosynostosis (craniofacial dysostosis) seen by the craniofacial team at the Hospital for Sick Children between 1986 and 1992. There were 51 patients with Crouzon's syndrome, 33 with Apert's syndrome, 8 with Pfeiffer syndrome, 11 with Saethre-Chotzen syndrome, and 4 with kleeblättschadel anomaly. Six patients developed raised intracranial pressure (ICP) after initial suture release and decompression (Apert's syndrome, three patients; Pfeiffer syndrome, one patient; Saethre-Chotzen syndrome, two patients). Raised ICP was considered in those children who returned with a bulging fontanelle, progressive frontal bone protrusion, intermittent headaches, irritability, and vomiting. The diagnosis of raised ICP was based on papilledema (four patients), progressive macrocephaly (one patient), and ICP monitoring (one patient). No child in this group had hydrocephalus requiring cerebrospinal fluid diversion. Once raised ICP was detected in these children, a second operation was immediately performed to reduce the ICP with the intention of expanding the volume of the cranial cavity. The second procedures included: anterior cranial vault and upper orbital reshaping (four patients), posterior cranial vault reshaping (one patient), and total cranial vault reshaping (one patient). There were no perioperative complications in these patients, although one patient showed subsequent recurrence of raised ICP requiring further cranial vault re-expansion. At follow-up, ranging from 3 to 7 years, all six patients were asymptomatic without evidence of raised ICP. In our series, raised ICP occurred in 6% of the children with a craniofacial dysostosis syndrome after initial suture release and decompression.(ABSTRACT TRUNCATED AT 250 WORDS)

The editors' labours: separating the wheat from the chaff

From the author's standpoint, the editor is viewed as 'one who separates the wheat from the chaff and then prints the chaff'! Since its inception, Pediatric Neurosurgery has tried to provide the reader with the guarantee that only the 'wheat' is published. This paper will examine the policies of the journal's Editorial Board and in particular outline the review process for submitted manuscripts. In addition to certain operational items, the paper will consider how the 'peer' in 'peer review' is identified, the grading instruments for paper acceptance, the likelihood that the readers and peer reviewers agree on manuscript quality, and how authors should view failure. The Society is firmly committed to our journal. Our individual responsibilities begin with paper preparation and then its presentation at the annual meeting. Thereafter, it is important for the membership to appreciate that their participation, as either author and/or reviewer, is critical for the continued success of our journal.

Encephaloceles of the anterior cranial fossa

From a total of 114 encephaloceles treated surgically at The Hospital for Sick Children in the 15 years to 1994, the case records of 17 patients with sincipital and 5 patients with basal defects were reviewed retrospectively. The condition was evident at birth in 64% of patients, while the remainder presented with either cerebrospinal fluid (CSF) rhinorrhea, nasal obstruction, or feeding difficulty. Hypertelorism affected 73% of patients. All encephaloceles were repaired transcranially, at a mean age of 2 years, usually by means of an intradural pericranial graft. Five children with gross hypertelorism underwent orbital translocation at the time of encephalocele repair. Of those not corrected, primary and secondary hypertelorism regressed in most instances where the encephalocele was treated before the age of 2 years. There were no deaths. The only case of CSF rhinorrhea occurred in a patient with a basal defect, in whom intradural repair was not possible because of adherence of diencephalic structures to the sac wall. Hypertelorism recurred in 1 patient after orbital translocation, requiring recorrection 2 years later. One patient with untreated secondary hypertelorism failed to regress after the encephalocele was excised at the age of 4 months. Developmental outcome was normal in 59% of children, whilst 18% have mild mental or physical disability, and 23% are severely impaired. A child with a sincipital or basal defect and mild hypertelorism should have the encephalocele treated in early childhood to allow the facial skeleton to remodel with growth. When an encephalocele is accompanied by gross hypertelorism or a facial cleft, one-stage correction can be undertaken safely in early childhood with minimal mortality and acceptable morbidity.

Benign cerebellar astrocytoma in childhood: experience at the Hospital for Sick Children 1980-1992

Between 1 January 1980, and 31 December 1992, 66 patients with cerebellar astrocytoma were diagnosed and treated at The Hospital for Sick Children in Toronto. These patients ranged in age between 1 and 18 years, with a mean age of 7.3 years. Thirty-eight patients were male and 28 were female. Total removal was possible in 61 patients and no recurrence occurred in these 61 patients. In the 5 patients in whom an incomplete resection was carried out, regrowth occurred between 1 and 8 years following resection.

Cerebral arteriovenous malformations in children

The treatment of cerebral arteriovenous malformations (AVM) or vascular anomalies are challenging neurosurgical procedures for an anaesthetist. Large AVMs are uncommon in children. Only 18% of AVMs become symptomatic before the age of 15 yr. This series reviews the experience at this institution during the period of 1982 to 1992. The symptoms at the time of presentation are varied and include haemorrhage (50%), seizures and hydrocephalus (36%) or congestive cardiac failure (18%). Symptoms of congestive heart failure predominate in the newborn whilst neurological symptoms, such as stroke, seizures or hydrocephalus occur more commonly in infants and older children. Approximately one third of AVMs in childhood present acutely. Radiological investigations, e.g., CT scan, MRI and cerebral angiography are essential to identify the precise location of the lesion. Therapeutic intervention in the acute presentation may involve craniotomy for evacuation of haematoma and treatment of increased intracranial pressure (ICP). Control of seizures and congestive heart failure may take priority and allow time to plan the elective procedures of embolization and surgical excision of the AVM. Operative intervention is hazardous and peroperative complications can be expected in more than 50% of patients. The morbidity and mortality associated with cerebral AVM are high, especially in infants who present in the neonatal period with congestive cardiac failure. The overall mortality in this series was 20%. Children presenting with intracranial arteriovenous malformations require a multidisciplinary approach. The successful management of anaesthesia either for embolization or surgical resection necessitates an understanding of the disciplines of paediatric and neuroanaesthesia. Special care and specific attention to detail may contribute to reduce the high morbidity and mortality encountered in these compromised children.

Colloid cysts in children

Three patients with colloid cysts were identified among approximately 1,400 patients with brain tumors seen at the Hospital for Sick Children in Toronto between 1952 and 1992. These and 34 previously published cases of colloid cysts in children were reviewed. Colloid cysts are rare causes of headaches and papilloedema in children. They usually present with chronic headaches and increased intracranial pressure. Although acute deterioration can occur at any time, it is uncommon. A CT scan or MRI with intravenous contrast is necessary to identify them, particularly those which are isodense. The growth, and subsequent postoperative recurrence of a colloid cyst in 1 youth argues for treatment by complete surgical excision in children.

Development of anaplastic changes in low-grade astrocytomas of childhood

The authors present their experience with six children who developed anaplastic astrocytomas after receiving treatment for low-grade astrocytomas. Five children were from a series of 55 children with optic chiasmatic-hypothalamic gliomas who have been studied since 1976. The sixth child initially had a low-grade astrocytoma of the thalamus. The mean age of the children at initial presentation was 5.3 years. Five children were treated with surgery and radiation therapy; one child with a chiasmatic-hypothalamic glioma received radiation therapy alone. The amount of external radiation therapy used in all children was 50-52.5 Gy delivered in standard fractionations over approximately 6 weeks to include the volume of the original tumor plus a margin of 2 cm. The time to anaplastic transformation varied between 2 and 10 years (mean, 6.4 years). At tumor recurrence, the children had seizures or symptoms and signs of raised intracranial pressure. The location of the second tumor in all patients was either at the primary site or within the field of radiation therapy. Five of the six children underwent a second craniotomy and subtotal resection of their malignant gliomas. One child had positive cerebrospinal fluid cytology and multiple intraspinal metastatic tumor nodules detected by magnetic resonance imaging. On histopathological examination, four children had anaplastic astrocytoma, and two had glioblastoma multiforme. Four of the six children have died of their anaplastic astrocytomas (mean time from diagnosis of anaplastic astrocytoma to death, 10 months). Two children underwent chemotherapy and spinal irradiation for their anaplastic astrocytomas, and are currently alive and undergoing treatment. The possible mechanisms by which anaplastic tumors have developed in children treated previously for low-grade astrocytomas is discussed. The data suggest that radiation therapy may have played an integral role in the genesis of anaplastic astrocytomas in these children.

Frameless stereotaxy in children

Frameless stereotaxy provides stereotactic localization without a standard stereotactic frame. Other reference points on the patient are linked to radiographic images by means of a three-dimensional (3D) digitizer. We report the use of a frameless stereotactic system to assist in 53 procedures in 52 children using the ISG Viewing Wand system (ISG Technologies, Missasauga, Ont.). This device uses surface landmarks as well as random surface points as the reference system. The three-dimensional digitizer consists of a six-jointed articulated arm to which pointers, a rigid ventriculoscope, or stereotactic biopsy probe guide can be attached. Image reconstruction is performed on standard CT or MRI (3D volume acquisition) images, with typically 3-mm slice thickness. The tip of the probe can be displayed on 3D surfaced objects which can be cut away to reveal reformatted gray scale displayed on the cut surface, or in a triorthogonal view where simultaneous reformatted coronal and sagital views at the level of the tip of the probe are displayed. Cases for which the viewing wand was used included craniotomies for tumor (30), vascular malformation (6), epilepsy surgery (5), other lesions (3), rigid ventriculoscopy (9), and stereotactic biopsy (2). The accuracy of the system was measured by placing 20 fiducial markers on a plastic head of which 3-mm thickness CT images had been made. The average error using 4 fiducials as reference points was 1.5 mm when the fiducials were distributed around the circumference of the head. Using random surface points of 10, 20 and 40 in number gave average errors of 2.3, 1.6, 1.5 mm, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Management and outcome of low-grade astrocytomas of the midline in children: a retrospective review

Low-grade astrocytomas of the midline of the brain can be difficult to manage because of their location. To evaluate treatment and outcome, we performed a retrospective study of children with midline low-grade astrocytomas admitted to The Hospital for Sick Children between 1976 and 1991. Eighty-eight children with biopsy-proven low-grade astrocytomas were identified. Forty-three tumors occurred in the optic pathways or hypothalamus, 13 in the thalamus, 7 in the pineal region, 14 in the midbrain, and 11 in the medulla. Patient follow-up ranged from 6 months to 15 years, with a mean of 4 years, 9 months. Overall outcome was related to the extent of resection, histological type, and location. Partial resections were often associated with involution of the tumor. Response to radiation was variable, and serious sequelae were observed. Thirty-three patients experienced recurrence, often with a good response to subsequent surgery; however, 12 of these patients died. The probability of survival was calculated to be 96% at 1 year, 91% at 5, and 80% at 10 years. Our study suggests that resection should be considered in all patients, both at presentation and recurrence.

Optic pathway/hypothalamic gliomas: a dilemma in management

Optic pathway gliomas follow an unpredictable course. Some remain static for years; others increase rapidly in size and often lead to death. This unpredictability, along with the histological similarity of these tumors, has resulted in controversy about their management. We have reviewed the results of management of all 62 patients with a diagnosis of optic pathway/hypothalamic glioma treated at The Hospital for Sick Children during the years 1976-1990. Twelve patients received no direct treatment, and 3 only a biopsy. Six patients were treated with radiotherapy alone. Eight patients received radiotherapy following a biopsy. Seventeen patients were treated by resection alone and 16 had a resection followed by radiotherapy. Eight patients received chemotherapy in addition to other therapy, and in 5 of them the chemotherapy was given as an initial therapy. Forty-eight patients are well with their visual deficits but 7 of them are receiving hormone replacement therapy. Six patients have significant neurologic deficits and 8 have died.

The long-term outcome after surgical treatment of dorsally exophytic brain-stem gliomas

Dorsally exophytic brain-stem gliomas represent a distinctive subgroup of pediatric brain-stem neoplasms that are amenable to radical excision because of their benign histology and growth characteristics. However, their attachment to the floor of the fourth ventricle invariably precludes complete tumor excision. The long-term behavior of the residual tumor remains a subject of concern. To address this issue, the authors reviewed their experience with 18 dorsally exophytic brain-stem gliomas treated between 1974 and 1990. At operation, the tumors filled the fourth ventricle, fungating out of a broad-based area of the dorsal brain stem. The exophytic tumor was resected, but no attempt was made to remove tumor from the brain stem. Histological examination showed that 16 of the tumors were grade I or II astrocytomas, one was a ganglioglioma, and one was an otherwise benign-appearing glioma with several foci of anaplasia that was classified as a grade III astrocytoma. The latter patient was one of only two in the series to receive postoperative radiation therapy; both cases so treated have no evidence of disease on follow-up imaging studies 61 and 135 months postoperatively. One other child who had stable disease postoperatively died of shunt malfunction 18 months after tumor excision. Serial radiographic studies in the other 15 patients have shown no evidence of disease in three, stable residual disease in eight, and tumor enlargement 12, 28, 40, and 84 months postoperatively in four (median follow-up period 113 months). Each of the four patients with tumor regrowth underwent repeat tumor excision. Two of these children received perioperative radiation therapy at the time of disease progression and both showed reduction in tumor volume 28 and 65 months after their second operation. In contrast, both patients who did not receive radiotherapy at the time of disease progression had further tumor enlargement 48 and 84 months after their second operation and underwent a third tumor resection; one received postoperative radiation therapy and has no evidence of disease 58 months after his third operation and the other child has stable disease 27 months postoperatively. Histological examination of tumor specimens obtained at second and third operations showed no change from the appearance of the tumor on the initial resection. The authors conclude that the majority of dorsally exophytic brain-stem gliomas can be managed successfully with subtotal excision and, if necessary, cerebrospinal fluid diversion. The small percentage of tumors in this series that showed recurrent growth remained benign histologically.(ABSTRACT TRUNCATED AT 400 WORDS)

A concerted effort to prevent shunt infection

In an attempt to reduce the rate of shunt infection a new protocol for shunt surgery was introduced on July 1, 1988 at The Hospital for Sick Children in Toronto. The operations were done at the beginning of the day, operating room personnel were kept to a minimum, no visitors were allowed in the room, a staff neurosurgeon or neurosurgical fellow attended all operations and two doses of perioperative cloxacillin 50 mg/kg were given intravenously. From July 1, 1988 to June 30, 1989 there were 576 shunt procedures on the Neurosurgical Service and 22 (3.8%) of these resulted in a shunt infection. During the preceding year (July 1, 1987 to June 30, 1988) 581 shunt operations were performed, 75 (12.9%) of which resulted in an infection (chi 2 = 29.9, P < 0.001). It appears that the introduction of this protocol for shunt surgery has helped to reduce the risk of shunt infection from 12.9% to 3.8% (a reduction of 70.5%). The rate of infection occurring after shunt revisions was not significantly different from that occurring after new shunt insertions. When the individual factors in the protocol were analyzed, the use of antibiotics and a shorter duration of surgery appeared to be related to a lower shunt infection rate.

Primary leptomeningeal melanoma: an unusually aggressive tumor in childhood

Primary malignant melanoma of the leptomeninges of the central nervous system is a rare and aggressive tumor in children. We report our experience from 1964 to 1990 with this tumor in eight children. The mean age at diagnosis was 4.9 years (range, 1.3 to 13 yr). Five children presented with signs and symptoms of raised intracranial pressure from hydrocephalus secondary to tumoral obliteration of the basal cisterns, but the time from the initial symptomatology to diagnosis was frequently delayed. Three patients in this series had hairy nevi in association with their leptomeningeal melanoma. Cerebrospinal fluid (CSF) analysis typically showed raised opening pressures, decreased glucose, and increased protein concentrations. Malignant melanoma cells were found in the CSF in three patients. Confirmatory radiographic examinations included air encephalography, myelography, and computed tomographic and magnetic resonance scanning. Four patients were treated with lumboperitoneal shunts, and one patient was treated with a ventriculoperitoneal shunt for hydrocephalus. Two patients underwent craniotomies and subtotal excisions of their tumors. In seven patients, a definitive diagnosis of leptomeningeal melanoma was made by pathological examination of tissues sent at surgery or at post mortem. In one case, the diagnosis was established by a detailed cytological analysis of the CSF. Four children died of fulminant disease and tumor spread before treatment could be instituted. The four children who received treatment had a combination of radiation therapy and chemotherapy. One child received intrathecal methotrexate. The two children with the longest survivals (2 and 3 yr, respectively) received cisplatinum and dimethyltriazenoimidazole carboxamide in addition to craniospinal irradiation.(ABSTRACT TRUNCATED AT 250 WORDS)

Hydrocephalus in Apert syndrome: a retrospective review

A retrospective evaluation was carried out to define the incidence of hydrocephalus and associated factors in 44 patients with Apert syndrome treated at The Hospital for Sick Children in Toronto over a 22-year period. Forty-three of these patients underwent cranioorbital decompressive procedures within 1 year of birth. Fifteen of 25 (60%) patients who had either a computed tomography scan or pneumoencephalogram had ventriculomegaly, and 3 of the 25 (12%) had associated brain anomalies. Ten of the 44 (23%) patients had cerebrospinal fluid (CSF) shunts placed, 7 lumboperitoneal and 3 ventriculoperitoneal. Six of the shunts were placed early after cranioorbital procedures (CSF leaks in 5 cases and a subgaleal fluid collection in 1 case). The average IQ of 15 patients evaluated by the Wechsler Intelligence Scale was 72.5, indicative of significant intellectual impairment. There was no correlation between IQ and ventricular size. Although hydrocephalus characterized by progressive ventricular dilatation is uncommon in Apert syndrome, postoperative problems related to impaired CSF circulation are common and may indicate an underlying CSF absorptive deficit.

Tonsillar herniation: the rule rather than the exception after lumboperitoneal shunting in the pediatric population

Although the development of tonsillar herniation (acquired Chiari malformation) in association with lumboperitoneal (LP) shunting is well recognized, it has previously been considered rare. In order to ascertain the incidence of this complication after LP shunting, the authors undertook a retrospective study of all patients in whom this form of shunt had been inserted between 1974 and 1991 at The Hospital for Sick Children, Toronto. In the 143 patients, the mean age at insertion was 3.3 years and the indications for shunt placement were hydrocephalus (81%), pseudotumor cerebri (7%), cerebrospinal fluid fistula (6%), and posterior fossa pseudomeningocele (6%). The mean follow-up period was 5.7 years, during which time there was one shunt-related death due to unsuspected tonsillar herniation. Five other patients developed symptomatic tonsillar herniation treated by suboccipital decompression. Review of all computerized tomography (CT) scans not degraded by artifact showed evidence of excess soft tissue at the level of the foramen magnum in 38 (70%) of 54 patients so studied. In order to confirm that this CT finding represented hindbrain herniation, sagittal and axial magnetic resonance (MR) images were obtained for 17 asymptomatic patients and revealed tonsillar herniation (range 2 to 21 mm) in 12 (70.6%). In addition, some of these asymptomatic patients had evidence of uncal herniation and mesencephalic distortion. Similarities and distinctions are drawn between the morphological changes occurring after LP shunting and those seen in association with the Chiari I and II malformations. Although less than 5% of this study population required treatment for tonsillar herniation, the incidence of this complication was high in asymptomatic patients; MR imaging surveillance for patients with LP shunts is therefore recommended.

Lumboperitoneal shunting: a retrospective study in the pediatric population

There is a shortage of data concerning the long-term follow-up of patients with lumboperitoneal (LP) shunts, especially in the pediatric population. A retrospective study of 143 patients who underwent LP shunting between 1974 and 1991 was therefore performed. The mean age at the time of shunt insertion was 3.3 years (range, 18 d to 17.8 yr), and the indication for shunting was: hydrocephalus (81%), cerebrospinal fluid fistula (12%), and pseudotumor cerebri (7%). The mean follow-up time was 5.7 years (range, 5 d to 17.5 yr), and during this period, there were five deaths of which one was shunt related (2.5 yr post-shunt insertion). Of the types of LP shunt used during the study period, the T-tube shunt (101 patients) fared significantly better (P = 0.003) than the percutaneous type (42 patients), and the overall survival characteristics for the T-tube shunt approximated those seen for ventriculoperitoneal shunts, with a 50% probability of remaining free of malfunctions for 5 years. A high rate of migration (19%) was partially responsible for the poor performance of the percutaneous-type shunts. By the end of the study, 40 patients (28%) had been converted to ventricular shunts, and this rate of conversion was similar for both shunt types. LP shunts have certain advantages over other forms of cerebrospinal fluid diversion and were successfully used for various clinical conditions during this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection and management of gangliogliomas in children

Forty-two children treated for gangliogliomas were reviewed to identify the best methods of detection and management. Thirty-two of the tumors were supratentorial, four infratentorial, and six were in the spinal cord. Twenty-five patients presented with seizures; the mean duration of symptoms was 5 years in contrast to 1 year in non-seizure patients. Of 31 children studied by computed tomography (CT), calcification in the tumor lesion was found in 19. Magnetic resonance imaging (MRI) showed abnormal high-signal intensity on T2 imaging in six of eight patients. All patients underwent surgical resection and were diagnosed pathologically. Twenty-four patients had total resection, and 14 underwent temporal lobectomies including hippocampectomy. The management of this tumor remains surgical resection without the need for any adjuvant therapy.

Retinal findings after head trauma in infants and young children

BACKGROUND

Many authorities believe that the finding of retinal hemorrhages in a child younger than 3 years of age with a history of head trauma, in the absence of an obvious cause for the injury, is pathognomonic of child abuse. To date, no studies have examined the prospective retinal examination of children who have had head trauma. The authors undertook such a study because the presence of retinal hemorrhage from any head trauma in children may have medicolegal diagnostic significance in differentiating accidental from nonaccidental trauma.

METHODS

Seventy-nine children younger than 3 years of age, each of whom experienced head injury, underwent an ophthalmologic assessment, which included a dilated funduscopic examination.

RESULTS

Seventy-five children sustained accidental head injuries and had normal funduscopic examinations. Three children had nonaccidental head injuries and all were found to have varying degrees of retinal hemorrhages. One child, with a normal fundus examination, had injuries that were of indeterminate cause.

CONCLUSION

The finding of retinal hemorrhages in a child with a head injury suggests a nonaccidental cause.

Surgical decompression for symptomatic Chiari II malformation in neonates with myelomeningocele

Between January, 1981, and July, 1991, 17 infants under 1 month of age were admitted to The Hospital for Sick Children with the signs and symptoms of a Chiari II malformation. These patients' presentation included swallowing difficulty (71%), stridor (59%), apneic spells (29%), aspiration (12%), weakness of cry (18%), and arm weakness (53%). Decompression of the Chiari II malformation was performed in all patients, with a time interval between onset of symptoms and surgery ranging from 1 to 121 days. Fifteen patients (88%) remain alive, all of whom have shown a complete recovery. The mean follow-up period in this group of patients was 65 months. Two patients died, one due to respiratory arrest 8 months after decompression and the other because of shunt infection and peritonitis 7 years after decompression. These results support the concept that compressive forces, rather than a primary intrinsic disorder of the brain-stem nuclei, play a crucial etiological role in the development of a symptomatic Chiari II malformation. Early recognition of the symptoms of Chiari II malformation should be followed by immediate decompressive laminectomy in order to promote a prompt and full neurological recovery.

Suprasellar and sellar tumors in childhood and adolescence

Suprasellar and sellar region tumors in children constitute a diverse group of lesions. We advocate an aggressive surgical approach to these tumors for diagnostic and therapeutic purposes. With detailed knowledge of the microneurosurgical anatomy of this region, the neurosurgeon can choose from a number of operative approaches on the basis of tumor size and location. The benefits of radiation therapy for craniopharyngiomas and optic chiasmatic/hypothalamic tumors must be carefully weighted against the substantial long-term risks associated with irradiation of the developing brain in this region. During the next decade, the role of primary chemotherapy for germinoma and adjuvant chemotherapy for optic pathway gliomas will be determined. Also, the role of stereotactic radiation therapy, of great value to some children with recalcitrant tumors in the suprasellar region, may be better defined.

Focal midbrain tumors in children

The clinical and neuroradiological features of focal midbrain tumors in 12 children are described, and the results of their surgical management are presented. Patients with a focal midbrain tumor usually exhibit either symptoms and signs of raised intracranial pressure caused by an obstructive hydrocephalus (50%) or symptoms and signs caused by pressure on the tegmentum and cerebral peduncles. The lesions are confined to the tectal plate or tegmentum with possible extension upward to the thalamus and downward to the pons, displacing but not invading these structures. The edges of the tumor are well defined, and the large majority have a solid consistency with intense regular enhancement after intravenous contrast. Radical resection is hardly ever feasible in brain stem tumors, but in this series, significant reduction of the tumor mass was obtained in 75% of the patients, with no surgical mortality and minimal surgical morbidity and with the majority of patients showing clinical improvement postoperatively. All tumors were nonpilocytic, low-grade astrocytomas. Six patients received adjunctive radiotherapy. The mean follow-up period is 2.5 years, and all patients are alive and doing well. We conclude that focal midbrain tumors in children appear to be a distinct subgroup of brain stem tumors and are very amenable to surgical resection with an excellent long-term prognosis.

A randomized controlled trial of perioperative rifampin/trimethoprim in cerebrospinal fluid shunt surgery

A randomized, double-blind, placebo-controlled trial of perioperative rifampin-trimethoprim was undertaken at the Hospital for Sick Children from March 1984 to October 1987, in which 243 patients undergoing 300 cerebrospinal fluid (CSF) shunting procedures were randomized into groups including treatment with rifampin/trimethoprim and placebo, and then followed for a minimum of 2 years. Patients were stratified prior to randomization into those with and those without meningo-myeloceles having first insertions of their shunts, and those having revisions. Patients could be entered into the study more than once, but always received the same treatment regimen once allocation had taken place. Among the patients receiving antibiotics there was an infection rate of 12%, versus 19% among patients receiving placebo. Among the surgical procedures, the rates were 9% and 15%, respectively. Because these rates of infection were a substantial increase over the rate of 7.5% overall for the few years prior to implementation of the study, and well over any acceptable rate of infection, the study was stopped before statistical significance was reached. However, had the study continued, and the proportions of patients becoming infected remained constant, we would have been able to achieve a statistically significant difference in rates of infection, and therefore demonstrate a benefit of rifampin/trimethoprim as prophylaxis against shunt infection. Methodological problems encountered in this and other studies of prevention of CSF shunt infection will be discussed.

Brain tumors in children and adolescents--III. Effects of radiation and hormone status on intelligence and on working, associative and serial-order memory

The effects on intelligence and memory of two post-surgical conditions (radiation treatment, hormone deficiency and supplementation) were explored in 46 children and adolescents with tumors in a variety of brain sites. Verbal intelligence, but not non-verbal intelligence, varied positively with age at radiation treatment. Memory for word meanings was unrelated to either radiation history or to hormone status. Severe deficits in serial position memory occurred with impaired hormone function and an older age at tumor onset. Severe deficits in working memory were associated with a history of radiation and a principal tumor site that involved thalamic/epithalamic brain regions. Radiation treatment and hormone status affect later cognitive function in children and adolescents with brain tumors. Although the greater vulnerability of the verbal intelligence of the younger radiated child and the serial order memory of the child with later tumor onset and hormone disturbances remain to be explained, and although the form of the relationship between radiation and tumor site is not fully understood, the data highlight the need to consider the cognitive consequences of pediatric brain tumors according to a set of markers that include maturational rate, hormone status, radiation history, and principal site of the tumor.

Arteriovenous malformations of the brain in children: a forty year experience

Despite the great capacity for the pediatric brain to recover from stroke, the morbidity and mortality in children who harbor an arteriovenous malformation (AVM) remains high. This study examines the clinical data and management experience with 132 patients with brain AVM from 1949 to 1989. Although the high tendency for a childhood AVM to present with hemorrhage (79%) remained constant for the forty year study period, the associated morbidity and mortality of hemorrhage changed. The mortality rate from hemorrhage for the entire series was 25%, which was reduced from 39% to 16% after the introduction of computed tomography. The mortality from AVM hemorrhage since 1975 was dependent on location; 8 of 14 patients (57%) with a cerebellar AVM died from hemorrhage while only 2 of 44 patients (4.5%) with a cerebral hemisphere AVM died (p less than 0.0001). Sixteen children (12%) presented with a chronic seizure disorder. Surgical excision of the malformation resulted in complete seizure control off anti-convulsant medication in 73% of patients. Although 21% of patients were treated non-operatively (many with terminal poor-grade hemorrhage), 79% had a surgical procedure with total AVM excision achieved in 70 patients (53.1%). Complete AVM resection was followed by a normal neurological outcome in 47 children (67%). Most partial excisions (n = 9) and clipping of feeding arteries (n = 7) were performed in the early years of this study, and did not provide protection from rehemorrhage. Although conservative management has been advocated for selected non-hemorrhagic AVMs, we conclude that essentially all children with an AVM should be treated in order to eliminate the risk of hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)

Aggressive surgical management of craniopharyngiomas in children

The cases of 50 patients with craniopharyngioma operated on at The Hospital for Sick Children in Toronto between January, 1975, and December, 1989, are reviewed. All patients were under 18 years of age (mean 9.39 years). Headaches, endocrine deficiencies, and visual deficits were the most common symptoms on admission. Forty-five patients underwent what was considered by the surgeon to be total excision of their tumor, and five had subtotal excision. Tumors recurred in 17 patients (mean time of recurrence 32.6 months after surgery). One patient died in the postoperative period and three have been lost to follow-up study. Of the remaining 46 patients, 28 are leading a normal or nearly normal life, although all are receiving endocrine replacement and some have required help to overcome mild deficits in memory or visual acuity. Twelve patients are able to function reasonably well and attend school despite being hampered by intellectual or visual deficits or problems with weight control; four have a significant handicap, and two have died.

Acoustic schwannomas in children

The clinical presentation and treatment of three cases of acoustic schwannoma occurring in children are described. All the tumors were detected late, when they had attained a large size and were extremely vascular. The use of preoperative tumor embolization as an adjunct to surgical excision is discussed.

Benign intrinsic tectal "tumors" in children

A specific group of intrinsic dorsal midbrain tumors was identified in six children by computerized tomography (CT) and magnetic resonance (MR) imaging. Each patient presented with raised intracranial pressure as a result of hydrocephalus due to obstruction of the sylvian aqueduct. No patient had brain-stem signs referable to the tectal tumor initially or subsequently. All six children underwent cerebrospinal fluid (CSF) diversionary procedures. The radiological features were consistent and specific, with all patients showing tectal calcification or primary increased attenuation of the tectal plate on CT scans. In addition, lack of contrast enhancement was noted initially in four patients and eventually in all six patients. In all patients MR imaging showed a focal tectal tumor distorting the collicular plate with no cystic component and increased signal intensity on T2-weighted images. There has been no evidence of progression in these six patients in the follow-up period ranging from 8 months to 17 years (8 months and 2 1/2, 4 1/2, 8, and 17 years). Diversion of CSF has been the only surgical treatment and no patient underwent deep x-ray therapy. Five patients have had normal intellectual development. In contrast to the majority of previously described periaqueductal and tectal tumors, this group of lesions appeared to be truly benign. The authors suggest that patients presenting with these clinical and radiological features may be managed by CSF diversion, serial examination, and MR imaging.

Apert syndrome. Diagnosis and treatment of craniostenosis and intracranial anomalies

Over the past 15 years, conceptual and technical advances have occurred in the management of the infant with Apert syndrome. There is greater understanding and hence documentation of the neurologic and developmental associations of Apert syndrome. The technical progress is measured in the maturation of former ad hoc, if not random, operative craniectomies, to current deliberate planned strategies with regard to management of hydrocephalus, synostosis, orbital expansion, and forehead advancement. The future will likely bring the prenatal diagnosis of Apert syndrome into even greater focus. That notwithstanding, management techniques are likely to change little in the next decade.

Intracranial germ-cell tumors in children

All patients with confirmed intracranial germ-cell tumors treated at the Hospital of Sick Children during the period January, 1952, to December, 1989, were reviewed. Of the 51 tumors reviewed, 16 were located in the suprasellar region, 32 in the pineal region, and three in both the pineal and the suprasellar regions. Forty-nine patients underwent surgical resection which was total in seven and partial in 20, and consisted of a biopsy in 22. Two patients were managed on the basis of serum and cerebrospinal fluid markers. Surgical tools such as the operating microscope, the ultrasonic surgical aspirator, and the laser beam allowed safe debulking and removal of the deep-seated tumors in the pineal region. There were no operative deaths in the 36 patients treated since 1972, who included 23 with pineal tumors. Twenty-five patients with germinomas received radiotherapy and had a 5-year survival rate of 85.1%. Thirteen patients with non-germinoma germ-cell tumors received radiotherapy and had a 5-year survival rate of 45.5%. On the basis of this review, the authors recommend resection of pineal and suprasellar germ-cell tumors in order to firmly establish an accurate histological diagnosis to guide the extent of adjuvant therapy. In the case of a pure germinoma without evidence of dissemination, adjuvant therapy consists only of local radiotherapy. On the other hand, for malignant non-germinoma germ-cell tumors, adjuvant therapy must include chemotherapy as well as craniospinal axis radiotherapy.

Accessory arm--dysraphism or disparity? Case report

The case of a 3-month-old infant with an accessory third arm is reported. The extra appendage was attached at the midcervical region and was associated with posterior cervical dysraphism and a cervical cord lipoma. Possible theories of origin are examined.

Mechanical complications in shunts

A retrospective study was conducted on 1,719 hydrocephalic patients, treated between 1974 and 1983 at the Hospital for Sick Children (Toronto) and l'Hôpital des Enfants Malades (Paris), in order to better understand shunt failure. The statistical analysis demonstrates the following: (1) A probability of occurrence of shunt malfunction of 81% at 12 years of follow-up. (2) A high prevalence of shunt obstruction (56.1% of all malfunction) and fracture or disconnection of the tubings (13.6%). (3) A higher risk of proximal occlusion with flanged ventricular catheter. (4) Less malfunction with proximal-non-slit valves as compared to distal-slit valves. (5) The importance of pressure-flow characteristics of the shunt; because of an indirect relation between overdrainage and proximal occlusion. (6) A correlation between connectors and migration or fracture of the shunt. (7) Less distal obstructions when an open-ended distal-catheter was used. These complications were of some clinical, psychological and economical consequences. Their rate could be lowed.

Brain tumors in children and adolescents--I. Effects on working, associative and serial-order memory of IQ, age at tumor onset and age of tumor

Memory impairment was demonstrated in a sample of 46 children and adolescents with brain tumors. The overall distribution of memory scores was skewed positively; over half of the total number of test measures were in the lowest quarter of the score distribution; and more than three-quarters of the individual subjects had at least one memory score in the impaired range. Verbal intelligence accounted for less than one-quarter of the variance in memory scores. The type of memory impairment was analyzed in relation to various demographic and medical variables: age at onset of tumor symptoms, age or duration of tumor, sex, pre-tumor developmental disturbances, pre-tumor closed head injury, post-tumor anticonvulsant treatment and post-tumor epileptic seizures. The working memory task, in which each in a succession of heard words is stored in temporary memory long enough to be compared to or contrasted with incoming words, was unaffected by these variables, as was memory for semantically-based word-picture associations. Memory for the serial order of pictures that corresponded to heard words varied inversely with the age at tumor onset such that the later the onset, the lower the memory test performance.