TROPHY registry - status report

INTRODUCTION

The TROPHY registry has been established to conduct an international multicenter prospective data collection on the surgical management of neonatal intraventricular hemorrhage (IVH)-related hydrocephalus to possibly contribute to future guidelines. The registry allows comparing the techniques established to treat hydrocephalus, such as external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). This first status report of the registry presents the results of the standard of care survey of participating centers assessed upon online registration.

METHODS

On the standard of treatment forms, each center indicated the institutional protocol of interventions performed for neonatal post-hemorrhagic hydrocephalus (nPHH) for a time period of 2 years (Y1 and Y2) before starting the active participation in the registry. In addition, the amount of patients enrolled so far and allocated to a treatment approach are reported.

RESULTS

According to the standard of treatment forms completed by 56 registered centers, fewer EVDs (Y1 55% Y2 46%) were used while more centers have implemented NEL (Y1 39%; Y2 52%) to treat nPHH. VAD (Y1 66%; Y2 66%) and VSGS (Y1 42%; Y2 41%) were used at a consistent rate during the 2 years. The majority of the centers used at least two different techniques to treat nPHH (43%), while 27% used only one technique, 21% used three, and 7% used even four different techniques. Patient data of 110 infants treated surgically between 9/2018 and 2/2021 (13% EVD, 15% VAD, 30% VSGS, and 43% NEL) were contributed by 29 centers.

CONCLUSIONS

Our results emphasize the varying strategies used for the treatment of nPHH. The international TROPHY registry has entered into a phase of growing patient recruitment. Further evaluation will be performed and published according to the registry protocol.

P04.15 Impact of histone lysine methyltransferases SETDB1, SETD2, SUV39H1, MLL2, EZH2and their corresponding histone marks in pediatric astrocytomas

BACKGROUND

Pediatric brain tumors are characterized by altered epigenetic profiles and deregulated chromatin remodelling that affects gene expression. Histone lysine methylation has emerged as important chromatin function regulator, with potential role in glioma formation. Τhis study investigates the expression of histone lysine methyltransferases (SETDB1, SUV39H1, EZH2, MLL2, SETD2) and their corresponding methylation marks (H3K9me3, H3K27me3, H3K4me2/3, H3K36me3) in pediatric astrocytomas.

MATERIAL AND METHODS

Thirty-four (34) archival pediatric astrocytomas [27 low grade (I/II) and 7 high grade (III/IV) tumors; 21 males, 13 females; 1–15 years old] and 5 postmortem normal brain samples were studied. Methyltransferases expression and histone marks were detected by immunohistochemistry as H-score (intensity multiplied with cell percentage, 0–300) and validated by western blot.

RESULTS

Elevated nuclear SETD2 and SETDB1 staining was observed in all astrocytomas (median H-score:165 and 110, respectively). SETDB1 and SETD2 expression levels were positively associated (p=0.004), being higher in high grade compared to lower grade tumors (p=0.001, p=0.027, respectively). Furthermore, SETDB1 staining was significantly increased in male children (p=0.051) and negatively associated with patients age (p=0.028). A moderate nuclear and cytoplasmic staining was obtained for MLL2 at low grade (median H-score:84) compared to high grade tumors (median H-score:144). In accordance, lower SUV39H1 nuclear and cytoplasmic expression was detected in low grade tissues (median H score:85) compared to high grade (median H-score:160). EZH2 presented no significant nuclear expression. Increased nuclear staining of H3K9me3 and H4K20me3 repressive marks was observed in astrocytomas (median H-score:297 and 270, respectively), being positively associated (p=0.02). Elevated nuclear staining of H3K4me3 active mark (median H-score:210) was detected in astrocytomas, being significantly higher in high grade tumors (p=0.025) and in male children (p=0.036).

CONCLUSION

SETDB1, SETD2, SUV39H1 and MLL2 may play a significant role in modulating gene expression in pediatric astrocytomas. Increased presence of H3K9me3, H4K20me3 and H3K4me3 histone marks signifies their possible participation in gliomagenesis.

Larger cohort studies need to elucidate the functional significance and underlying molecular mechanisms of these chromatin-modifying enzymes and respective histone changes in pediatric astrocytomas.

Acquired Chiari I malformation in a child with corrected diastematomyelia disappeared after thickened filum division

INTRODUCTION

In recent years there has been renewed interest in the relation between Chiari I malformation and spinal cord tethering.

CASE REPORT

A 3-year-old girl presented with right leg pain. At spinal MR scan there was diastematomyelia with a bony peg at L1 and syringomyelia at T10-11. She had a surgical repair of the diastematomyelia without filum division. Symptoms settled postoperatively. A few months later she started displaying weakness in the right leg and loss of bulkiness of the right calf. A new MR scan showed a new Chiari I malformation, which was not present in the preoperative MR scan. The syringomyelia cavity was smaller. There was low-ending conus medullaris at L3 and a thickened filum. The filum was divided 15 months after the first operation. At MR scan obtained 18 months after filum division, the previously noted acquired Chiari I malformation had disappeared.

DISCUSSION

There is no obvious explanation for the formation of acquired Chiari I malformation and its disappearance after filum division. Recently, there has been description of patients with Chiari I malformation and normal posterior fossa volume, who were treated with filum division, and their Chiari malformation regressed without craniovertebral decompression surgery. Nevertheless, it is difficult to explain how traction on the lowest aspect of the spinal cord could lead to herniation of the cerebellar tonsils through the foramen magnum.

Malfunction of SynchroMed II baclofen pump delivers a near-lethal baclofen overdose

INTRODUCTION

Intrathecal baclofen therapy using implantable pumps is an established treatment for spasticity. The pumps occasionally experience serious malfunction.

CASE REPORT

A 12-year-old girl suffering from spastic diplegia was implanted with a Medtronic SynchroMed II pump (Medtronic Inc., Minneapolis, Minn., USA). During a refill at 3 months 19 ml of baclofen were still in the pump. It was assumed that there was a lumbar catheter obstruction and a revision was performed. At 11 months she was receiving 180 microg/day. When she presented for refill, there were again 19 ml of baclofen in the reservoir. The pump was refilled, stopped and restarted at a lower dose. Ten minutes after restart the patient was complaining that she could not move her legs. Within the next 50 min she lapsed into coma, from a presumed baclofen overdose. She was intubated and ventilated. The reservoir was emptied of baclofen and the pump stopped. Seventeen hours after the baclofen overdose, the patient woke up gradually with no new neurological deficits. The pump was removed a week later. Medtronic laboratories examined the pump and reported no technical fault.

DISCUSSION

The implanted Medtronic SynchroMed II pump suffered an unusual malfunction. It is postulated that the pump had suffered a motor stall, and when it was restarted, it gave an unusually high, potentially lethal, dose to the patient.

CONCLUSION

Physicians who implant pumps for intrathecal baclofen administration need to be aware that these devices may suffer unheralded catastrophic failure that can lead to potentially lethal overdose administration.

Brain tissue oxygenation changes in children during the first 24 h following head injury

AIM

The aim of this study is to assess the changes of brain tissue oxygen levels in children during the first 24 h following head injury and its correlation with changes of intracranial pressure and clinical outcome.

METHOD

Invasive monitoring of partial brain tissue oxygen tension (PbtO(2)) using the Licox (Integra Neurosciences, Plainsboro, NJ, USA) oxygen probe was performed in children with severe head injury requiring ventilation, during the years 2002-2005. The study focused in the recordings of the first 24 h following injury.

RESULTS

There were four patients (three males, one female) with an age range of 2-12 years. All injuries were due to motor vehicle accidents. The Glasgow Coma Score ranged from 5 to 9. All patients had diffuse axonal injuries on Computed Tomography scan. One patient underwent a bilateral decompressive craniectomy. The total duration of monitoring was 567.84 h. During the first 24 h, the mean PbtO(2) was 4.2 mmHg, 12.7 mmHg, 21.8 mmHg, and 25.1 mmHg in each patient. Fifteen episodes of ICP>20 mmHg were seen in the first 24 h of monitoring. Nine of these episodes were accompanied by a reduction in PbtO(2) levels. The Glasgow Outcome Score at 1 year was good recovery (GOS 3) in three patients and severe disability in one patient. There were no complications from the monitoring.

CONCLUSIONS

In children with head injury, rise in ICP may be accompanied by fall in PbtO(2). However, low brain oxygen levels during the first 24 h following head injury may not correlate necessarily with poor outcome.

Identification and characterisation of childhood cerebellar tumours by in vivo proton MRS

(1)H MRS has great potential for the clinical investigation of childhood brain tumours, but the low incidence in, and difficulties of performing trials on, children have hampered progress in this area. Most studies have used a long-TE, thus limiting the metabolite information obtained, and multivariate analysis has been largely unexplored. Thirty-five children with untreated cerebellar tumours (18 medulloblastomas, 12 pilocytic astrocytomas and five ependymomas) were investigated using a single-voxel short-TE PRESS sequence on a 1.5 T scanner. Spectra were analysed using LCModel to yield metabolite profiles, and key metabolite assignments were verified by comparison with high-resolution magic-angle-spinning NMR of representative tumour biopsy samples. In addition to univariate metabolite comparisons, the use of multivariate classifiers was investigated. Principal component analysis was used for dimension reduction, and linear discriminant analysis was used for variable selection and classification. A bootstrap cross-validation method suitable for estimating the true performance of classifiers in small datasets was used. The discriminant function coefficients were stable and showed that medulloblastomas were characterised by high taurine, phosphocholine and glutamate and low glutamine, astrocytomas were distinguished by low creatine and high N-acetylaspartate, and ependymomas were differentiated by high myo-inositol and glycerophosphocholine. The same metabolite features were seen in NMR spectra of ex vivo samples. Successful classification was achieved for glial-cell (astrocytoma + ependymoma) versus non-glial-cell (medulloblastoma) tumours, with a bootstrap 0.632 + error, e(B.632+), of 5.3%. For astrocytoma vs medulloblastoma and astrocytoma vs medulloblastoma vs ependymoma classification, the e(B.632+) was 6.9% and 7.1%, respectively. The study showed that (1)H MRS detects key differences in the metabolite profiles for the main types of childhood cerebellar tumours and that discriminant analysis of metabolite profiles is a promising tool for classification. The findings warrant confirmation by larger multi-centre studies.

Comparison of prenatal and postnatal MRI findings in the evaluation of intrauterine CNS anomalies requiring postnatal neurosurgical treatment

AIM

To assess the diagnostic capability of fetal magnetic resonance imaging (MRI) in children suspected antenatally to harbor central nervous system (CNS) defects that require immediate postnatal neurosurgical treatment.

MATERIALS AND METHODS

Between 2003 and 2005, 13 fetal MRI scans were performed in mothers suspected to have fetuses with congenital CNS defects that would require surgery soon after birth. Comparisons between antenatal and postnatal scans were made with emphasis on diagnostic accuracy of antenatal examinations.

RESULTS

All mothers were scanned using heavily T2-weighted fat-saturated sequences, allowing rapid acquisitions to avoid movement artefacts. Imaging quality was satisfactory in all patients. Diagnoses made antenatally were: myelomeningocele in seven, meningocele in one, diastematomyelia in one, occipital meningocele in one, and isolated hydrocephalus in three children. Of the seven children with antenatal diagnosis of myelomeningocele, one proved to have spinal lipoma postnatally. The patient who antenatally was diagnosed with meningocele proved to have spinal lipoma postnatally. These two were early antenatal MR scans. Antenatal diagnosis of hydrocephalus was made in five of the six confirmed myelomeningocele patients, which was verified postnatally. Antenatal diagnosis of Chiari II malformation was made in all six confirmed myelomeningocele patients. The antenatal diagnoses of occipital meningo-encephalocele and isolated hydrocephalus were verified postnatally. Antenatal diagnosis of diastematomyelia was not verified postnatally.

CONCLUSION

Fetal MRI scanning is an effective, noninvasive method of assessing in-utero CNS abnormalities. The diagnostic accuracy has improved to allow prediction of clinical outcome and counseling for possible treatment, but is not perfect yet to allow counseling for termination of pregnancy.

Pattern, management and outcome of cervical spine injuries associated with head injuries in paediatric patients

INTRODUCTION

This study examines the management and outcome of cervical spine injuries in children with head injuries, to assess the need for surgical treatment.

MATERIAL AND METHODS

We performed a retrospective analysis (1995-2005) of 445 children admitted intubated and ventilated to the intensive care unit with head injuries.

OUTCOME MEASURES

Frankel grade for spinal injuries and Glasgow Outcome Scale (GOS) for head injuries.

RESULTS

Cervical spine injuries were detected in 11 patients (incidence 2.5%, mean age: 6.3 years, range: 21 months-15 years). The injuries were: C1/2 distraction: 2; C1/2 subluxation: 2; odontoid peg fracture with C1/2 dislocation and cord transection: 1; disruption of posterior longitudinal ligament at C2: 1; odontoid peg fracture with C2/3 distraction: 1; C2/3 subluxation: 1; C3 lamina fracture: 1; C3/4 facet fracture: 1; C6/7 fracture dislocation with cord transection: 1. One patient was managed operatively, ten patients nonoperatively, two with halo vests and eight with hard collars. There were three deaths (mortality 27%) associated with severe head injuries. At 6 months follow-up, two patients remained quadriplegic (Frankel Grade A), one of them ventilator dependent, one had residual motor function but of no practical use (Frankel Grade C), five had good spinal outcome (Frankel Grade E). Seven patients had good head injury outcomes (GOS 5), one remained disabled (GOS 3).

CONCLUSION

Most children with cervical injury can be managed nonoperatively with good outcomes. Surgical management may be necessary in severe unstable injuries.

Clinical trial: The effect of somatostatin vs. octreotide in preventing post-endoscopic increase in hepatic venous pressure gradient in cirrhotics with bleeding varices

BACKGROUND

Hepatic venous pressure gradient (HVPG) increases significantly after endoscopic therapy in patients with bleeding oesophageal varices, which may precipitate further haemorrhage. Whether vasoactive drugs can suppress these changes remains unknown.

AIM

To investigate the efficacy of somatostatin when compared with octreotide in preventing the post-endoscopic increase in HVPG during acute bleeding and whether the changes affect outcome.

METHODS

Thirty-three cirrhotics with bleeding varices were randomized to receive somatostatin (n = 17) or octreotide (n = 16) under double-blind conditions, soon after their admission. HVPG measurements were performed before and immediately after endoscopic treatment.

RESULTS

In the somatostatin group, postendotherapy HVPG values did not change significantly when compared with pre-treatment values (18.9 vs. 17.2, P = 0.092). Conversely, in the octreotide group, HVPG increased significantly after endoscopy (18.2 vs. 20.8, P = 0.003). The probability of 6-week survival without treatment failure was significantly higher in the somatostatin group (P = 0.024). Post-endoscopic HVPG value was independently associated with 6-week failure.

CONCLUSIONS

Somatostatin, but not octreotide, effectively prevents the post-endoscopic increase in HVPG, which may be associated with low probability of treatment failure.

Surgical management of spasticity of cerebral origin in children

In children, spasticity is commonly seen in the context of cerebral palsy (CP), but also following head injury, cerebral infarct or other brain insults. CP is a wide term used to describe a constellation of symptoms that characterise the physical impairment of movement due to abnormal brain development. The management of spasticity is tailored according to the clinical picture of the child. Ambulatory mild spastic diplegics tend to reach the maximum of their disability in the first few years of life, and change little after the age of 5-7 years. Such patients who are between 3-5 years and who attempt to mobilise with walking frames are often good candidates for either dorsal rhizotomy or intrathecal baclofen (ITB) administration with the implantation of an indwelling pump. Non-ambulatory mild spastic diplegics and spastic quadriplegics have more profound spasticity, painful spasms, orthopaedic deformities, and difficulties with daily care and posture. ITB has become established as the first line of surgical treatment for these patients. In the last decade, there has been a definite trend away from ablative treatments and towards reversible stimulation and infusion systems. Current pumps have practical limitations but, in the next decade, it is anticipated that technological improvements will render the pumps more patient friendly.

Incidence of vascular malformations in spontaneous intra-cerebral haemorrhage in children

AIM

To assess the incidence of vascular malformations in children presenting with non-traumatic intra-cerebral haemorrhage and outline the need for radiological investigations.

MATERIALS AND METHODS

Between 1993 and 2002, 26 children presented with spontaneous intra-cerebral haemorrhage at a mean age of 26 months (range 1-192 months).

RESULTS

Twenty-two children had, as first treatment, surgical removal of the haematoma and any malformation found. One patient with no evidence of vascular malformation had conservative treatment, two had embolisation and one had stereotactic radiosurgery of arteriovenous malformations (AVMs). The diagnosis of vascular malformation was confirmed histologically and/or radiologically in 16 (61%) patients. Of these 16 patients, 7 were AVMs, 1 thrombosed middle cerebral artery (MCA) aneurysm, 1 cavernous angioma, 6 aggregates of abnormal vessels, 1 vein of Galen aneurysm. Pre-operatively, 12 patients had magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) and 7 were positive for vascular malformation (1 false positive) with no false negatives. Digital subtraction angiography (DSA) was performed pre-operatively in 7 patients, 4 were positive with no false negatives. There were no re-bleeds at the follow-up period. Five (19%) patients died from the haemorrhage, 7 (27%) had severe neurological deficit and 14 (54%) had no neurological deficit. Residual malformation after surgery requiring additional treatment was found in 3 (16%) patients. All patients with confirmed malformations were followed-up with DSA.

CONCLUSION

MRI/MRA has high sensitivity and specificity in identifying vascular malformations in children presenting acutely with spontaneous intra-cerebral haemorrhage. This may prove useful when pre-operative DSA is not promptly available. After acute clot evacuation, there is high incidence of residual malformation and such patients should be followed-up with DSA.

Bilateral exudative retinal detachment in a child with orbital pseudotumor

We describe a 15-year-old girl who presented with bilateral exudative retinal detachment, a previously unreported complication, due to orbital pseudotumor. She initially responded to steroids, but subsequently became steroid dependent. Azathioprine was effective in controlling further relapses during follow-up of 22 months.

Diastematomyelia in children: treatment outcome and natural history of associated syringomyelia

OBJECTIVE

To quantify the long-term outcome of children with diastematomyelia and the implication of syringomyelia in the natural history.

MATERIALS

Retrospective study of 17 children (nine girls and eight boys) with diastematomyelia operated during 1989-2004. Mean age at diagnosis was 3.4 years (range 5 days-12 years), mean follow-up was 5 years; 14 had excision of spur and cord untethering, 3 had excision of spur alone.

RESULTS

The bony spur was in the lumbar region in 12 and thoracic in 5 patients. Syringomyelia was present in eight (47%), associated with bony spur between L1 and 4 (p=0.088), spina bifida occulta in ten (58.8%), and spinal lipoma in one (6%). Preoperative Necker Enfants Malades (NEM) scores were 17 in eight patients, 16 in four, 15 in three, 13 in one, and 12 in one patient. Presenting neurological deficits were motor in eight, sensory deficits in three, and anal incontinence in one patient. There was improvement of NEM scores postoperatively in five patients only, but still with residual deficit. Repeat spur excision and cord untethering was performed in three patients for neurological deterioration 1-4 years after first operation. On postoperative MRI scans syringomyelia remained unchanged in all eight patients. There were one skin infection, one transient motor deterioration, and one patient with sensory deficit after surgery.

CONCLUSION

Prophylactic operations were associated with the best clinical outcome. Despite improvement, all patients with established preoperative deficit still had residual neurological deficits at their last follow-up. The associated syringomyelia remained unchanged after surgery, indicating that it does not contribute to the neurological syndrome.

Outcome of children with posterior fossa medulloblastoma: a single institution experience over the decade 1994-2003

AIM

While the impact of radiotherapy in the management of medulloblastoma was recognised, the introduction of chemotherapy was investigated in clinical trials and shown to confer an additional advantage. We reviewed the outcome of a series of consecutive patients to assess the impact in a population-based clinical establishment.

MATERIALS AND METHODS

A series of 38 children treated for medulloblastoma at Birmingham Children's Hospital between 1994 and 2003 was analysed. The effect of surgery, radiotherapy, chemotherapy and metastasis on survival was analysed.

RESULTS

The overall 5-year survival rate was 61.4% for the 36 patients who had resective surgery, while 2 patients had biopsy only and died within a few months. There was no operative mortality. The incidence of hydrocephalus needing permanent shunting was higher in the first 3 years of life (p = 0.007, chi-square). The 5-year survival rate of patients with total and sub-total excision of medulloblastoma was 61.1% and 61.8%, respectively. The 5-year survival rate of patients older than 3 years was 73.4% and for patients under 3 years was 36.3% (p = 0.007, log rank). Metastases at presentation did not influence survival. All deaths occurred in the first 32 months.

CONCLUSION

The contribution of chemotherapy in the improvement of the overall survival appears more evident in children younger than 3 years or presenting with metastases. The absence of significant difference in survival between patients with total or sub-total excision of medulloblastoma supports the view that total excision of medulloblastoma can be avoided when the risk for potential intra-operative damage and consequent neurological deficits is high.

Short echo time 1 H magnetic resonance spectroscopy of childhood brain tumours

AIMS

To explore short echo time (30 ms) 1 H magnetic resonance spectroscopy (MRS) in children with brain tumours and determine the contributions to the characterization of these tumours of the metabolites inositol/myoinositol and glutamate/glutamine, which are not visible at long echo times (135 or 270 ms).

METHODS

Over a 12-month period 86 single-voxel MRS investigations were performed on 59 children with various brain tumours on a Siemens Symphony 1.5-T Magnetom using point-resolved spectroscopy and echo time of 30 ms.

RESULTS

The procedure was well tolerated, and good-quality data were obtained. N-Acetyl aspartate (NAA)/Choline (Cho) and creatine (Cr)/Cho concentration ratios were significantly (p<0.001) lower in tumour (0.95 and 1.63, respectively) compared with non-involved brain (3.68 and 3.98, respectively) in all histological types. Inositol/Myoinositol (Inos)/Cho ratios were significantly (p<0.05) lower in untreated tumours (1.91) than in treated tumours (3.93) and in non-involved brain (3.32). Inos/Cho ratios were high in diffuse pontine gliomas and low in medulloblastomas and supratentorial primitive neuroectodermal tumours (p<0.01). Glutamate/Glutamine (Glut)/Cho ratios were high in grade 1 astrocytomas (6.4) and unbiopsied optic gliomas (9.84) but low in diffuse pontine gliomas (2.44). Lipids and macromolecules were present in most tumours but in low quantities in non-involved brain.

CONCLUSION

Good-quality short echo time MRS data can be collected routinely on children with brain tumours. Inos and Glut levels show greater variability between tumour types than NAA, Cho and Cr present at long echo times, providing improved tumour characterization. Inos/Cho levels differ between untreated and treated tumours and may be useful for treatment monitoring.

Prophylactic antibiotics in pediatric shunt surgery

INTRODUCTION

The optimal antibiotic prophylaxis for pediatric shunt-related procedures is not clear. There is much inconsistency among different medical centers. This paper summarizes and analyzes the various prophylactic antibiotic regiments used for shunt-related surgeries at different pediatric neurosurgery centers in the world.

MATERIALS AND METHODS

A survey questionnaire was distributed through the Pediatric Neurosurgery list-server (an e-mail-based special interest group in pediatric neurosurgery). Forty-five completed questionnaires were received, one per medical center, primarily from pediatric neurosurgeons with the following geographic breakdown: 25 from North America, 13 from Europe, and 7 from Asia and other countries. All centers routinely administered prophylactic antibiotics for shunt-related procedures. The drugs of choice were first-generation cephalosporins (23), second-generation cephalosporins (10), naficillin/oxacillin (4), vancomycin (3), clindamycin (1), amoxicillin (1), and mixed protocols in three centers. The initial drug administration ("first dose") was: in the department before transfer to operating room (5), upon arrival to operating room (11), at induction of anesthesia (13), and at initial skin incision (16). The duration of antibiotic dosage also varied: single dose (13), 24-h administration (26), 48-h administration (2), and longer than 48 h in four centers.

RESULTS AND DISCUSSION

Two general tendencies were noted, common to the majority of participating centers. There was a general trend to modify antibiotic treatment protocol in "high-risk" populations. The second common theme noted in more than half of responding centers was the use of long-term antibiotic treatment for externalized devices (such as externalized shunts, external ventricular drains or lumbar drains), usually till the device was in place.

Assessment of the influence of operative factors in the success of endoscopic third ventriculostomy in children

OBJECTIVE

To determine if operative factors correlate with success of endoscopic third ventriculostomy (ETV) in the treatment of hydrocephalus.

MATERIALS AND METHODS

The ETV procedure video of 33 hydrocephalic children was reviewed. Mean age at operation was 76 months (range: 1-196). Success was defined as no need for shunt in the long term. We calculated the relative size of stoma as the percentage of stoma diameter to the distance between posterior clinoid-basilar artery. Factors analysed were: intra-operative haemorrhage, stoma size, thick/double third ventricular floor, pre-pontine adhesions presence, brisk cerebro-spinal fluid (CSF) flow through the stoma as well as hydrocephalus cause, previous shunt presence, CSF infection or haemorrhage and previous ETV. Analysis was performed using chi-square, linear regression, and one-way ANOVA.

RESULTS

Overall ETV success rate was 42%. Mean stoma size was 37%. For the entire group, none of the operative factors correlated statistically with success. Previous shunt presence adversely correlated with success (p=0.008). The highest success rate was in the aqueduct stenosis group. In patients without previous shunt (n=17), stoma size over 30% tended towards significance (p=0.094), CSF leak was adversely associated with ETV success (p=0.041) and mean stoma size was 41.3% in successful ETV and 27.8% in unsuccessful ETV (p=0.072). In patients with previous shunt (n=16), thin third ventricular floor was a negative predisposing factor (p=0.057).

CONCLUSION

This study did not demonstrate a correlation between the presence of pre-pontine adhesions, double or thickened floor of third ventricle and ETV success. In patients without previous shunt, stoma size may correlate with success. CSF leak was strongly associated with failure.

Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury

INTRODUCTION

We compared the effect of early decompressive craniectomy (<24 h) vs non-operative treatment on the outcome of children with refractory intracranial hypertension after severe traumatic brain injury.

MATERIAL AND METHODS

We retrospectively reviewed 12 consecutive patients treated between 1999 and 2001 for refractory intracranial hypertension after isolated severe head injury without any intracranial haematomas. In all patients, treatment included sedation, paralysis and i.v. mannitol under intracranial pressure monitoring. Early decompressive craniectomy was carried out in six patients (mean age: 13 years) at mean time from injury of 7 h (range: 2-18 h), whereas six patients (mean age: 11.5 years) were managed with non-operative treatment. The Marshall Grading system was used to score the severity of radiological abnormalities in CT scans. The Glasgow Outcome Scale (GOS) at 1-year follow-up was used as outcome measure.

RESULTS

The mean Marshall grade was 3 in the craniectomy group and 2 in the non-operative group. All patients in the craniectomy group survived: four patients scored 5 and two patients scored 4 on the GOS. In the non-operative group, two patients (33%) died, one of whom received late decompressive craniectomy at 9 days, while three patients scored 5 and one patient scored 3 on the GOS.

CONCLUSION

In children who suffered severe head injury with refractory intracranial hypertension without intracranial haematoma, early decompressive craniectomy employed in the first few hours after injury before the onset of irreversible ischaemic changes may be an effective method to treat the secondary deterioration that commonly leads to death or severe neurological deficit.

The International Infant Hydrocephalus Study: concept and rational

INTRODUCTION

During the recent meetings of the International Study Group on Neuroendoscopy and the International Society for Pediatric Neurosurgery, the consensus view emerged that there is a need to assess the value and efficacy of neuroendoscopic procedures against shunting in a scientific manner, to resolve long-lasting debates on the subject.

MATERIAL AND METHODS

A prospective randomized, controlled trial of endoscopic third ventriculostomy vs shunting in children presenting under the age of 2 years with pure aqueduct stenosis is been proposed and organized (the International Infant Hydrocephalus Study, IIHS). The participating surgeons must adhere to the philosophy of randomization and be suitably experienced in endoscopic techniques in infants. The primary outcome of the trial will be the overall health-related quality of life of these children at 5 years of age. Hence, the study is focusing on the effect of surgery on neurodevelopment, rather than the less important issue of shunt or stoma survival, that has been debated extensively with no conclusion so far. Intention-to-treat analysis will be performed according to the first surgery. Secondary outcomes such as complication and reoperation rate, total hospitalization time and cost, need for repeat imaging, and others will be analyzed as well.

RESULTS

Pure aqueduct stenosis is relatively rare, making recruitment problematic, but has been chosen to avoid other confounding factors that could influence outcome. More than 25 centers worldwide have committed already to patient recruitment to the study. It is anticipated that recruitment will last for 2 years, aiming for 91 patients per arm. The study has started recruiting patients already in some countries.

CONCLUSION

It is hoped that the trial will not only provide answers to unsettled debates on the value of neuroendoscopy but also create a network of collaborating pediatric neurosurgeons for future initiatives.

Extradural spinal arachnoid cysts associated with spina bifida occulta

INTRODUCTION

Spinal extradural arachnoid cysts are an uncommon cause of neural compression in children. Even more uncommon is the association of such cysts with spina bifida occulta.

MATERIAL

Two girls, 12 and 8-years-old, presented with left leg pain, deteriorating gait, clinical signs of left L5 and S1 root compression, without bladder or bowel symptoms. The first patient had left foot drop. The second patient had muscle wasting and smaller left foot with pes cavus. Radiographs showed spina bifida occulta of S1 in both. MRI revealed an extradural cyst at the S1 level, indenting the thecal sac and the L5 and S1 roots. At operation in both patients a large arachnoid cyst arising from a small dural defect in the axilla of the left S1 root was compressing and displacing it and the dural sac. It was removed and the defect was repaired. The first patient improved with complete recovery of the foot drop. An MRI at 12 months showed no cyst recurrence. The second patient made good recovery initially, but at 10 months developed recurrent symptoms. An MRI scan showed recurrence of the cyst with root compression. On repeat exploration a different dural defect was identified in a more anterior position and was repaired.

DISCUSSION

The coexistence of extradural arachnoid cyst and corresponding bifid spinal segment has not been described previously. It raises the suspicion that the dural defect giving rise to the arachnoid cyst may be due to segmental dural dysgenesis in the context of the dysrhaphic neuroectodermal malformation.

Spontaneous resolution of isolated Chiari I malformation

INTRODUCTION

Spontaneous resolution of Chiari I abnormality is very rare. In most patients, the radiological abnormality either stays unchanged with time or deriorates.

CASE REPORT

We present a male patient who was diagnosed at the age of 18 months as having radiological evidence of Chiari I malformation without syringomyelia, which had resolved 5 years later on a subsequent MR scan. At the time of initial diagnosis, he had been experiencing recurrent jerking movements of his body and was a sufferer of chronic renal failure.

DISCUSSION

The symptoms were thought to be unrelated to the hindbrain hernia. Such spontaneous resolution of an isolated Chiari I malformation has only been described once more before, although resolution of hindbrain hernia associated with syringomyelia has been described before in several cases, albeit at single figures. The mechanism for such a natural evolution is not clear.

CONCLUSION

This patient demonstrates that surgical treatment should not be considered hastily in patients with radiological evidence of Chiari I in the absence of convincing associated clinical symptoms.

The use of an adjustable valve to treat over-drainage of a cyst-peritoneal shunt in a child with a large sylvian fissure arachnoid cyst

INTRODUCTION

The cyst-peritoneal shunt is a recognised surgical alternative in the management of sylvian fissure arachnoid cysts. Shunt overdrainage is well described in literature on ventriculo-peritoneal shunts, but not often appreciated as a complication of cysto-peritoneal shunts.

CASE REPORT

A 5-year-old boy presented with a symptomatic left sylvian fissure arachnoid cyst. This was initially treated by craniotomy and membrane fenestration in the carotid cistern. Recurrence led to insertion of a valveless cyst-peritoneal shunt 5 months later. Initial progress was followed by persistent headaches 18 months after shunt insertion. CT scan revealed a significant reduction in the cyst size, enlargement of the ipsilateral lateral ventricle, collapse of the contra-lateral ventricle and midline shift towards the side of the shunt. These findings were interpreted as over-drainage of the cyst-peritoneal shunt.

RESULT

A Codman Medos adjustable valve was inserted, with the intention of gradually increasing the pressure until the midline shift was restored and the contra-lateral ventricle was reconstituted. This was achieved with the valve set at 90 mm H(2)O, verified by CT scan. Radiological improvement was associated with dramatic symptomatic improvement.

CONCLUSION

Over-drainage of cyst-peritoneal shunts is often not appreciated, especially when the main manifestation is headaches. As it is difficult to predict the required valve pressure setting, it may be advisable to consider the use of an adjustable valve.

Cranioplasty in children

OBJECTIVE

The objective was to assess the outcome and complications associated with different cranioplasty implant materials in children.

MATERIALS AND METHODS

A retrospective review was conducted of 28 consecutive cranioplasties carried out on 24 children between 1994 and 2001 (age range, 9 months to 15 years; minimum follow-up 18 months). The indications were: defect from previous craniectomy for trauma, tumour, infection or evacuation of haematoma (n=21), intradiploic dermoid cysts (n=2), growing fractures (n=4) and residual bony defect following craniofacial reconstruction (n=1). The materials used were: patient's craniectomised bone flap (n=16), split calvarial graft (n=8), acrylic (n=3) and titanium (n=1). All patients were assessed for bony fixation, cosmesis, wound healing and flap infection.

RESULTS

There was no mortality and 18% morbidity (n=5: 3 infected flaps, 1 sterile wound dehiscence and 1 sterile wound discharge; overall infection rate 10%). Out of the 14 patients who had their own craniectomised bone flaps implanted initially, 3 became infected (2 in patients with bilateral defects) necessitating flap removal. Two of these were successfully re-implanted. No donor or recipient bone flap complications were seen in the 8 split calvarial grafts, wound discharge was seen in 1, requiring wound toilet. No complications were seen with acrylic or titanium cranioplasties.

CONCLUSION

In this series, the use of the patients' own craniectomised flap had a low infection rate, and was mainly seen in patients who had bilateral flaps re-implanted soon after removal. There were no complications arising from the use of split calvarial and allograft material. Use of autologous implant material should be preferred whenever possible due to obvious resource and biological advantages, and can even be re-implanted if infected.

Adaptation of skull clamp for use in image-guided surgery of children in the first 2 years of life

INTRODUCTION

We describe a simple but effective modification of the skull clamp, aimed at stabilising the head of very young children, while avoiding the risk of creating a depressed skull fracture, in order to enable the utilisation of image-guidance in such young patients.

METHODS

We machined three small perspex discs 3 cm in diameter. On the outer surface of these pads we drilled reception holes for the pins to prevent slippage. To avoid direct contact with the skin, we interfaced a thick pad of soft felt. During intraoperative positioning, the weight of the head was supported by a suction bean-bag placed on the operating table. Hence, the clamp apparatus was employed only to secure the head position, and not to support the weight of the head, thus requiring less clamp force. We employed this modification in three children (aged 9, 13 and 15 months) who required image-guided surgery for brain tumours.

OUTCOME

In all cases the head remained immobile throughout the operation, making possible the accurate use of image guidance. At the end of the operation, some transient skin redness was noticed in the contact areas, which settled in a few days.

Stereotactic biopsy of brain tumours in the paediatric population

OBJECTIVE

Our objective was to establish the role of stereotactic neurosurgical techniques in the management of brain tumours in children.

MATERIALS AND METHODS

A retrospective analysis was conducted of all stereotactic procedures performed in a single centre between 1996 and 2001. The success rates of achieving histologic diagnosis and a correlation between radiologic and histologic diagnosis were examined.

RESULTS

There were 7 boys and 7 girls with a mean age of 9.1 years (range: 4-15). Under general anaesthetic 15 procedures were performed in 14 patients: 12 diagnostic and 3 therapeutic; 10 with CT and 5 with MRI guidance; 10 lesions were supratentorial and 4 were in the pons. A definitive histologic diagnosis was established in 10 of the 12 cases (diagnostic yield 83%). The pre-operative radiological diagnosis was accurate for tumour type in only 75% of the cases. In 3 patients cyst aspiration was attempted: post-operatively the cyst size was decreased in 2 and unchanged in 1. Seizures and acute confusion following biopsy of a thalamic tumour occurred in 1 patient. Post-operative scans were performed in 7 patients and in 2 we noted small, clinically insignificant, haemorrhages at the biopsy site. There was no mortality and morbidity was 6.6%.

CONCLUSIONS

This small series confirms that stereotactic procedures in children are safe, well tolerated, with a high diagnostic yield, which could be improved with the use of intraoperative histopathological examination.

Investigation of extracellular amino acid release in children with severe head injury using microdialysis. A pilot study

Microdialysis has been used to investigate the pathophysiology of severe head injury in adults. No similar data exist, however, for children. As part of routine neuromonitoring, five children with severe, closed head injury (GCS < 8) were fitted with a microdialysis probe (CMA 70) at the time of intracranial pressure bolt insertion. Samples were collected at hourly intervals prior to analysis of amino acids by High Performance Liquid Chromatography. In contrast to adult patients, glutamate and aspartate did not correlate with structural amino acid levels and were inversely related to glutamine levels, suggesting that excitatory aminoacid release in children with severe head injury is likely to be an active process rather than an effect of indiscriminate cell destruction and that glutamate levels extracellularly may also depend on glutamate uptake and metabolism. The nitric oxide metabolite citrulline remained at similar levels in different patients throughout the monitoring period, indicating that nitric oxide metabolism may not follow the pattern of glutamate release. Our study is suggesting that amino acid release in severe head injury in children may not correspond to the recognised patterns from cell culture and animal studies and may also differ from that in adults.

The effect of intrathecal baclofen on muscle co-contraction in children with spasticity of cerebral origin

AIM

Investigation of the effect of intrathecal baclofen administration on the time course of electrical patterns of muscle activation in patients with spasticity due to upper motor neuron syndrome.

METHODS

Six children with clinical signs of upper motor neuron syndrome resulting from an acquired cerebral hypoxic injury were tested. Simultaneous multichannel acquisition of surface EMG activity from flexor/extensor muscle groups of the upper and lower limbs was recorded. Investigated muscle group pairs included biceps/triceps brachii, wrist flexors/extensors, rectus/biceps femoris and tibialis anterioris/gastrocnemius. Time-frequency analysis of EMG activity at rest and while eliciting a stretch reflex was performed. The non-linear cross-correlation coefficient and time lag estimation were computed between paired channel groups both for baseline and post-intrathecal baclofen injection conditions for epochs consisting of 2 s prior to and 2 s after voluntary contraction. The effect of baclofen was assessed 3 h following single-bolus intrathecal injections of 25 or 50 microg during the baclofen trial and 6 months after baclofen pump implantation.

RESULTS

In the baseline condition, the stretch reflex resulted in a synchronous increase in spectral EMG power in both the agonist and the antagonist muscles. The mean correlation coefficient between agonist and antagonist muscles was 0.948 (SD = 0.034), and the mean time lag was 4.64 ms (SD = 1.84 ms). After intrathecal administration of baclofen, a dramatic decrease in the correlation coefficient between agonist and antagonists (mean value = 0.342) during voluntary contraction was observed. This corresponded to a significant reduction of tone and spasticity in all four limbs, and reduction of the Ashworth score by 2 points on average.

CONCLUSION

After intrathecal baclofen administration, we observed a significant decrease in the co-contraction pattern typically associated with upper motor neuron spasticity. This was evident clinically and was quantitatively expressed by the significantly decreased degree of coupling in EMG activity of agonist/antagonist muscles. Although a relatively small sample was investigated in this study, we were able to demonstrate the efficacy of this procedure in restoring selective activation of agonists during voluntary contraction. This is one of the prerequisites of an improvement of motor function in patients with spasticity.

Spinal lipoma misinterpreted as a meningomyelocele on antenatal MRI scan in a baby girl

INTRODUCTION

Antenatal screening for spina bifida with ultrasound and MR imaging is increasingly used.

CASE REPORT

A baby girl's antenatal MRI examination showed features originally interpreted as a lumbar meningomyelocele. Repeat MRI examination soon after birth showed features of a spinal lipoma (lipomeningomyelocele). This was excised surgically and complete spinal cord untethering was achieved.

CONCLUSION

As antenatal MR scanning is increasingly used, and fetal surgery is becoming more prominent, the correct interpretation of such images is crucial. We present a rare case of a misleading antenatal radiological diagnosis of spina bifida, which would have had severe implications if termination of the pregnancy or intra-uterine surgical repair had been considered.

Spinal sagittal malalignment following surgery for primary intramedullary tumours in children

BACKGROUND/OBJECTIVE

As prior studies analysed predictive factors for various post-laminectomy spinal deformities in mixed spinal regions, age groups or pathologies, their validity and conclusions were unclear. The objective of this study was to determine predictive factors for worsened cervical or thoracic spinal sagittal alignment following laminectomy or laminotomy for primary intramedullary spinal cord tumours in children.

METHODS

In this retrospective study, patients treated between 1980 and 1998 were reviewed. Changes in spinal alignment at the last follow-up compared to the pre-operative state were studied. Factors analysed were age, pre-operative spinal alignment, procedure types (laminectomy or laminoplasty), number of laminae operated, surgery of C2 or T1 laminae, histological grade, presence of post-operative neurological deficit and post-operative radiotherapy.

RESULTS

There were 27 patients. The mean age was 5.6 years (range 1.3-14.0 years), and the mean duration of follow-up was 3.7 years (range 0.075-9.9 years). In the cervical-cervicothoracic surgical group (n = 12), alignment worsened post-operatively in 3 patients. The number of laminae operated upon had a statistically significant impact on the development of post-operative kyphosis (p = 0.07). In the thoracic-thoracolumbar surgical group (n = 15), alignment worsened in 9 patients. Procedure types were statistically significantly different, with laminectomy associated with an increased risk of post-operative kyphosis (p = 0.01). All 5 patients who had spinal fusion for worsened post-operative alignment were in the thoracic-thoracolumbar group; no patients in the cervical-cervicothoracic group required spinal fusion (p = 0.047). Other predictive factors did not reach statistical significance (p > 0.05).

CONCLUSIONS

Worsened spinal sagittal alignment following laminectomy or laminoplasty and the need for spinal fusion is more common in the thoracic-thoracolumbar region than in the cervical-cervicothoracic region. In the cervical-cervicothoracic region, operation on a greater number of laminae tends to increase the risk of worsened alignment. In the thoracic-thoracolumbar region, laminectomy is associated with worsened alignment, while laminoplasty reduces this risk; also, pre-operative kyphotic deformity tends to increase the risk of worsened alignment post-operatively.

Congenital middle fossa arachnoid cysts may cause global brain ischaemia: a study with 99Tc-hexamethylpropyleneamineoxime single photon emission computerised tomography scans

Three children with middle fossa arachnoid cysts, presenting with non-specific symptoms and otherwise well, were investigated before and after surgery with magnetic resonance and 99Tc-hexamethylpropyleneamineoxime single photon emission computerised tomography scans, to assess the effect of the cysts on cerebral blood flow. All patients had evidence of a reduction in cerebral blood flow at presentation, even in the hemisphere contralateral to the middle fossa cyst, implied by perfusion defects seen centrally in the deep white matter of both cerebral hemispheres. After successful surgical excision of the cyst, the perfusion defects disappeared. This was associated with general improvement of pre-existing non-specific symptoms. These findings indicate that middle fossa arachnoid cysts may cause global impairment of brain function by interfering with its blood supply. This does not support the generally held view that such cysts are benign in nature when 'asymptomatic'.

Spontaneous spinal epidural abscess in a neonate. With a review of the literature

Spinal epidural abscess is uncommon in neonates and infants, and is usually related to previous lumbar puncture or epidural anaesthesia. Diagnosis is often delayed because of the non-specific presentation. We present a 7-week-old girl who developed paraplegia 3 weeks after transient fever and a self-limiting skin rash. MR imaging revealed an epidural contrast-enhancing lesion compressing the spinal cord. At operation, an organised granulated abscess was identified with Staphylococcus aureus the causative organism. Laminectomy and removal of the organised abscess and systemic intravenous antibiotics resulted in complete neurological recovery. The patient did not develop late spinal deformity following the decompressive laminectomy. The rapid onset of paraplegia can often be missed in such a young child but should be promptly investigated, as surgical treatment of cord compression carries an excellent prognosis for neurological recovery. We review the literature on the initial presentation, usual investigations, causative organisms and surgical management of paediatric spinal epidural abscesses.

The Influence of hair shave on the infection rate in neurosurgery. A prospective study

OBJECTIVE

To investigate whether not shaving hair in neurosurgical operations carries an increased infection rate.

METHODS

Taking advantage of different practices among neurosurgeons in a single institution, we embarked upon a prospective non-randomised study of 100 consecutive neurosurgical procedures involving 90 paediatric patients aged 7 days to 16.8 years. The patients were split into two groups ('hair shave' and 'no hair shave'). The differences with respect to wound complications, positive microbiology on wound culture swabs and wound infection rates were analysed. Other factors considered were the cleansing solution, prophylactic antibiotic regime, duration of the operation, the surgeon's experience and the patient's age.

RESULTS

The only complications observed were 4 incidences of wound dehiscence (2 in the hair shave and 2 in the no hair shave group) and 3 shunt infections (2 in the hair shave and 1 in the no hair shave group). We did not find any significant difference between the two arms for any of the factors assessed. Age was a significant factor in shunt infection, as all shunt infections were seen in patients aged less than 6 months, regardless of whether the hair was shaved or not (p = 0.024, Fisher's exact test).

CONCLUSION

This study confirms our clinical experience that no hair shave is a good alternative to the traditional hair shaving approach, allowing patients to enjoy the psychological benefits of undisturbed body image while recovering from major surgery.

Cerebral abscess associated with a pulmonary arteriovenous malformation in a patient suffering from alpha thalassaemia

We report the case of a young girl suffering from alpha thalassaemia and presenting with a brain abscess caused by a silent pulmonary arteriovenous malformation. To our knowledge this is the first such case associated with alpha thalassaemia. Diagnostic investigations and treatment options are discussed.

The clinical value of electroencephalogram/magnetic resonance imaging co-registration and three-dimensional reconstruction in the surgical treatment of epileptogenic lesions

With the rapid developments in image processing, new clinical applications of manipulation and three-dimensional (3-D) reconstruction of neuro-imaging are evolving. Combination with other non-invasive techniques aimed at localising electric sources in the brain is of particular interest. These techniques rely on the recording of brain electrical activity and/or the associated magnetic fields from multiple areas on the scalp. Data obtained from an electroencephalogram (EEG) or from magnetoencephalography (MEG) can be fused in 3-D arrangement with anatomical [magnetic resonance imaging/computerised tomography (MRI/CT)] and/or metabolic [positron emission tomography (PET)] data. Such techniques highlight information on the functional correlates of anatomical or space-occupying lesions and their role in the localisation of related symptomatic epilepsy. In the present study we report on methodological issues and preliminary clinical data on spectral EEG/MRI co-registration procedures, offering two examples of children presenting with hemispheric lesions, one frontal tumour and one temporal arterio-venous malformation. The EEG was acquired from 32/64 electrode location. The electrode position and that of four reference points were measured with a dual sensor Polhemus 3D Isotrak digitiser. Sources of EEG activity were determined in 3-D space with the inverse solution method low resolution electromagnetic tomography (LORETA), providing for each frequency component, the topographic distribution of active electrical sources. The positions of the reference points were also measured on MRI, and co-registration of EEG and MRI was achieved using a transformation algorithm. The reconstructed 3-D images of co-registered EEG/MRI clearly demonstrate the relationship between the space-occupying lesion and the epileptic activity. Preliminary results show that in all the patients it was possible to identify with a remarkable accuracy the 3-D topographic relationship between lesion and cortical areas showing localised abnormalities on the EEG. The present method could further enhance the understanding of the effect of resective treatment of structural lesions on brain functioning. The new combined images can be used in combination with image-guided surgery equipment to modify effective surgical resection.

Cervical disc prolapse in childhood associated with Klippel-Feil syndrome

Klippel-Feil syndrome is characterized by a variable degree of congenital fusion of the cervical spine. It can exist in association with other mesodermal deformities affecting several systems. Symptomatic cervical disc prolapse in the context of the syndrome is well documented in young adults. We present a case of a 5-year-old girl with the syndrome, who presented with mild motor developmental delay and cervical cord compression from a prolapsed C3/4 intervertebral disc, seen on MR scan. She also had posterior elements fused from C-2 to C-4. She improved after cervical discectomy. The presence of degenerative disc disease at such a young age and at a level mechanically protected by posterior element fusion indicates a congenital primary defect, rather than mechanical stress fatigue.

Ocular manifestations of hindbrain-related syringomyelia and outcome following craniovertebral decompression

PURPOSE

To analyse and evaluate associated ocular symptoms and signs in hindbrain-related syringomyelia and their response to treatment.

METHODS

From a database of 275 patients treated in a single institution for hindbrain hernia and syringomyelia, 39 patients (14%) had ocular symptoms and signs. Only 31 patients were included in this study; the remainder were excluded due to inadequate follow-up information. All patients had confirmed evidence of hindbrain-related syringomyelia with MRI scan or CT myelogram. Treatment included craniovertebral decompression or ventriculo-peritoneal shunting. The mean follow-up was 23 months.

RESULTS

In addition to the well-recognised sign of downbeat nystagmus, classically associated with foramen magnum abnormalities, a number of other ophthalmic features were identified. Symptoms included diplopia, oscillopsia, tunnel vision and difficulty in lateral gaze. Signs included nystagmus (downbeat, horizontal, rotatory, and combinations), strabismus, disc pallor, anisocoria, ptosis and field defect. Patients were categorised into two groups depending on whether the ocular features were manifest at first presentation (group 1, n = 14) or developed later in the course of the disease (group 2, n = 17). The delay in diagnosis from first presentation was 5 and 6 years respectively. All patients underwent surgery. Craniovertebral decompression was performed in 13 patients in group 1 and in 15 patients in group 2. Ventriculo-peritoneal shunt was inserted in 1 patient in group 1 and in 3 patients in group 2, for the associated hydrocephalus. Following surgery, 100% of patients in group 1 and 82% of patients in group 2 had complete or partial resolution of their ocular symptoms and signs.

CONCLUSIONS

The presence of unexplained ophthalmic features such as nystagmus or oscillopsia should alert one to the potential diagnosis of hindbrain-related syringomyelia. Delay in diagnosis is often associated with poorer outcome. Surgical treatment can offer excellent results for these patients.

Intraventricular haemorrhage due to ruptured posterior inferior cerebellar artery aneurysm in tuberculous meningitis

A 9-year-old Asian boy with known miliary tuberculosis, tuberculous meningitis and hydrocephalus was successfully treated with chemotherapy and ventriculoperitoneal shunting, but re-presented 7 months later with an intraventricular haemorrhage secondary to a ruptured left posterior inferior cerebellar artery mycotic aneurysm. The aneurysm was successfully treated by craniotomy and clipping. Tuberculous mycotic intracranial aneurysms are rare, but they should be considered in patients with tuberculous meningitis, particularly when there is a rapid neurological deterioration which may represent rupture.

Outcome of surgical treatment for subdural fluid collections in infants

We reviewed retrospectively the management of 47 infants with subdural collections at the Birmingham Children's Hospital. Of those patients who had needle aspiration as their initial treatment 42% required some form of further treatment and 25% were complicated by infection of the subdural collection. Of those patients treated with burr hole evacuation or with observation alone, 78 and 73%, respectively, required no further procedures. However, 17% of those who had burr holes as their initial treatment developed post-operative infected collections. Of those who had subdural-peritoneal shunt as initial or subsequent treatment, none required further procedures to treat the subdural collections. No infections were noted following shunting. There was no statistically significant difference in overall clinical outcome at last follow-up between the different treatment groups. We conclude that needle aspirations should be avoided due to high infection risk, and that observation alone can be sufficient in the absence of intracranial hypertension, as the condition may be self-limiting. In cases requiring surgery, it should be borne in mind that burr hole evacuation has a higher infection risk, whereas subdural shunting has the additional need for removal of the device if the parents and surgeon decide accordingly.