|Year : 2010 | Volume
| Issue : 2 | Page : 173-181
Neuropedicon 2010, Hyderabad 20th - 21st November, 2010
|Date of Web Publication||24-Jan-2011|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Neuropedicon 2010, Hyderabad 20th - 21st November, 2010. J Pediatr Neurosci 2010;5:173-81
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1. Supratentorial Glioblastoma in Children
Dwarakanath S., Sampath S., Chandramouli B. A.,
Indira Devi B.
National Institute of Mental Health and Neurosciences, Bangalore -29, India
Introduction: Glioblastoma is a malignant tumour of neuroepithelial origin, is relatively uncommon in childhood and is predominantly supratentorial. Material and Methods: This retrospective study included all paediatric patients (<18 years) underwent surgery for supratentorial glioblastoma between Jan 2002 to Dec 2009 at our institute. Their demographic, clinico-radiologic features, management strategies, adjuvant therapy and long term follow up were analysed. Results: There were total 37 cases operated, the mean age of presentation being 10-12 years (n=11), the most common site was frontal lobe (n=14), the most common presentation being raised ICP without localisation (n=18).Radiologically there were heterodense solid lesions (n=25), cystic lesions (n=8) and lesions with bleed (n=4). All patients underwent craniotomy and decompression. Mean follow up was 10-30 months (avg 18 months). Recurrence was noted in 11 cases. Mean survival was 22-24 months, longest survival in our series is 8 years. Conclusion: Paediatric Glioblastomas is rare and distinct entity. Most common site and presenting symptoms are same as adult glioblastomas and paediatric glioblastomas from other series and our results are co-relating with available literature. Better survival and delayed recurrence were noted in patients treated with postoperative adjuvant therapy.
Keywords: Glioblastoma, Paediatric, Supratentorial
2. Infantile Intracranial Brain Tumours
Mohanty C., Shukla D., Devi B. I., Chandramouli B. A., Sampath S., Santosh V.*
Departments of Neurosurgery, *Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
Neonatal neoplasms Intracranial tumours are second most common neoplasms in infants having a distinct behaviour and prognosis compared to adults. There is a paucity of literature regarding this entity. 45 cases of brain tumours in children of upto 2 yrs of age were treated in the last 15 years. 24 patients had symptoms onset at age less than 1 year. Out of these 24 only 21 records were available for retrospective analysis. None of the cases had an associated congenital anomaly or family history of malignancy. Choroid plexus papilloma (cpp) was the commonest tumour constituting 7/21 cases, followed by Medulloblastoma in 3/21. Thirteen cases had supratentorial tumours while 8 cases had infratentorial tumours. Twelve cases were benign and 9 were malignant. Gross total resection was achieved in 8/21 cases while near total excision was achieved in 3/21 cases. CSF diversion procedure was done in 10 cases as a part of primary treatment (6 underwent a shunt, while 4 underwent endoscopic CSF diversion) while one more patient underwent shunt after the primary surgery during follow-up period. Complications were noted in 7/21 patients like hydrocephalus and subdural hematomas. One child expired on postop day 1. Range of follow-up was 1 - 127 months, with median follow-up duration of 8 months. Good outcome was noted in 11/21 patients. Cpp is commonest brain tumour in infants. Surgery for infantile brain tumours is challenging and associated with high morbidity. Long term prognosis is good for benign tumour but very bad for malignant tumours.
Key Words: Brain tumors of infancy, Congenital tumours,
3. Neuro progenitor cell Imaging with MRS and evaluation of new biomarkers in patients with cortical malformations
Rammohan Vadapalli 1 , Kpottal 1 , Sita Jayalakshmi 2
1 Vijaya Diagnostics and Research, 2 Nizam's Institute of Medical Sciences, Hyderabad, India
Purpose: To evaluate the role of Neuro progenitor cell Signal and associated Biomarkers in patients with Cortical Malformations. Materials and Methods: 25 patients in age groups of 2-13 years with cortical malformations who have visited our Out patient for follow up scan for refractory epilepsy and 25 age and sex matched Controls are included in the study after the IRB approval. All patients had undergone a comprehensive Epilepsy protocol on a 3T MRI system and in addition a MR spectroscopy exam using short and Long TE from Both Hippocampi and Cortical malformation Zone and Ipsilateral normal Cortex. Then DTI exam was performed using a B value of 2000 and 15 directions and FA values were calculated from cortical malformation, Ipsilateral and Contra lateral Cortices and Hippocampi. 6 Tract graphic trajectories from the clock face of ROIs between Hippocampi and Malformations are then constructed and called as probable Migrational pathways. Values were analyzed for following: NPC signal in hippocampi and cortex, Hippocampal Myoinsitol: cortical Myoinsoitol ratio A. from malformation and B. from normal contra lateral cortex, Hippocampal FA: Cortical malformation FA ratio, FA values along 6 probable migrational pathways were then Analyzed. Results: There were following Types of Cortical malformations: Hemi megalencephaly (n=2), FCD (n=13), Poly Microgyria (n=8), Perisylvian syndromes (n=2) In Normals (n=17) and Patient group (n=11) NPC signal was seen on MRS at 1.28ppm (?a phospho lipid) The mean Hippocampal and Cortical Myoinositol ratio was 0.8 from the normal cortex and 0.45 at site of malformations. Cortical and Hippocampal FA value ratio in Normal controls was 1 and in patients with focal cortical malformations about 0.5 Tract trajectories with FA weighting between cortical malformations and ipsilateral Cortex reconstructed from six ROI show variable FA in malformation and Hippocampi Conclusion: Cortical Dysplasias are migrational anomalies which cause refractory epilepsy and neuroprogenitor cell (NPC) imaging and associated emerging biomarkers adds new characterization information. Clinical Relevance: Neurogenesis can be in vivo mapped by NPC signal on MRS. This study yields new biomarkers which help us to understand the neurogenesis and Migration in Normals and in Patients with Cortical malformations.
4. Posterior fossa craniotomy for trapped fourth ventricle in shunted hydrocephalic children - long-term outcome
Udayakumaran S., Biyani N., Rosenbaum D. P., Constantini S., Beni-Adani L.
Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv University, Tel Aviv, 64239, Israel
Trapped fourth ventricle (TFV) is a rare late complication of postinfectious (PIH) or post hemorrhagic hydrocephalus (PHH). As this entity is mostly found in premature children with cerebral palsy, diagnosis and treatment options are a true challenge. During the period February 1998 - February 2007, 12 children were treated for TFV in Dana Children's hospital by posterior fossa craniotomy and opening of the TFV into the spinal subarachnoid space. The data was retrospectively collected and analyzed. We performed 13 fenestrations of trapped fourth ventricle (FTFV) in 12 patients. In 6 patients with prominent arachnoid thickening, a stent was left from the opened fourth ventricle into the spinal subarachnoid space. One patient had second FTFV 21 months later. No perioperative complications were encountered. All 12 patients (100%) showed clinical improvement after fenestration of the trapped fourth ventricle (FTFV). Radiological improvement was seen in only 9/12 (75%). The follow period was 2 - 9.5 years mean 6 th + 2.2 years after FTFV. Fenestration of the trapped fourth ventricle via craniotomy is a safe and effective option with a very good long-term outcome and low morbidity.
Keywords: Trapped fourth ventricle, neuroendoscopy, foramen magnum decompression, posterior fossa craniotomy, fenestration of trapped fourth ventricle.
5. Encephaloceles: A study of 110 patients at AIIMS over all 8 years period (2002-2009)
A. K. Mahapatra
All India Institute of Medical Sciences, India
Introduction and Objective: Encephalocele are rare clinical entity encountered in neurosurgical practice. Over the years only few published papers from India. This paper analyses 110 patients operated at AIIMS, Neurosurgery, to find out types, age incideces radiological findings and out come of these children. Material Method, Observation and Results: Over a 8 years period (2002-2009), 110 Encephalocele were treated at the Dept. Neurosurgery, AIIMS. This retrospective data is analyzed from computer data base to study age incidence, type of encephalocele and the outcome of surgery. Vast majority patients were under 2 years of age. Eight patients were between 5-10 years. 10 patients were neonate less than 30 days. All the patients had CT scan and over 30% also had MRI, in addition. Sixty these patients had occipital encephaloceles thirty patients had anterior encephalocele and seven had parietal encephaloceles. Eleven patients had Giant Encephaloceles (10%), of which 9 were Occipital and 2 anterieor encephaloceles. Patients with hydrocephalus were subjected to CSF diversion in form of V.P. shunt. All the patients except one was not operated, Anterrior encephalocele patients, in addition to repair of encephaloceles also underwent corrective osteotomies for hypertelorisim, when the hypertelorisim was significant. Overall results were good. There was 5 postoperative death (4.5%). Two were neonates with Giant Occipital Encephaloceles, who developed hypothermia during surgery and did not recover. One patient of occipital encephaphalocele developed wound break down followed by fulminant meningitis, leading to death. The fourth mortality was in a 7 th month old child, who underwent surgery for anteriror encephalocele, and post op aspiration pnemonitis leading to death. Encephalocele are rare and accounts less than 0.5% of our patients undergoing surgery. Occipital encephaloceles accounted accuted for 65% followed by anterior encephaloceles 29%. Overall, result of surgery was good with a mortality of 4.5%.
6. Clinical and surgical outcome of adolescent pituitary adenomas
V. Ravikanth. Suchanda, A. K. Purohit, B. P. Sahu,
M. Vijayasaradhi, Praveen
Pituitary adenomas are rare in childhood and adolescence accounting for 2.7% of all supratentorial tumors in childhood. However most of them are functional. The aim of this study was to analyze the clinical behavior and surgical outcome of pituitary tumors in childhood and adolescent age group. This is a retrospective study where all the patients admitted between 2005 January to 2009 December were analyzed. The patients' details were taken from the Neurosurgical database and the operation theatre records. There were 8 adolescent patients with pituitary adenomas among the 65.no. of pituitary adenomas operated at NIMS between 2005 to 2009). All patients had a detailed clinical examination, endrocrinological, ophthalmological and radiological investigation prior to surgery. Post surgically patients were investigated with the required hormonal assessment and with MRI to see for the extent of excision. There were five male and three females in this series. Patient age at the onset of symptoms ranged from 8 to 16 years (mean, 10.5 yrs), and age at surgery ranged from 13.5 to 19.5 years (mean, 15.5 yr). 76% of patients presented with endocrinological symptoms (6 of 8), like amenorrhea -3, galactorrhea-1, gynecomastia-1 and 50% presented with visual symptoms. Endocrinalogically 4 patients had elevated prolactin levels, serum Cortisol elevated in two patients one of which also had raised ACTH. Radiological investigations demonstrated Hardy grade I in three patients, grade II in two, grade IV C in 1 and grade IV.D in two patients with invasive macro adenoma with parasellar extension. Surgery was done in all 8 patients. Five patients underwent trans sphenoidal excision among them one patient required a second transcranial exploration. Three patients underwent transcranial approach and subtotal excision performed. Surgical morbidity consisted of visual deterioration in one patient and death in another. Seven patients showed improvement endocrinalogically in the postoperative period. Three patients were started on Cabergolin and followed up routinely. Follow-up duration was 6 to 24 months (mean 10.9 months). There was no recurrence. Immune histo chemistry suggestive of prolactinomas in three patients, silent prolactinoma in two, and corticotrophic adenoma in two, pleuriharmonal adenoma in one patient. This series once again correlates with literature that this is an infrequent disease in pediatric group and functional adenomas are more common in childhood and adolescent group. They assume huge size and surgery is the preferred mode of treatment followed by adjuvant therapy like ant horm.
7. Trends in presentations of spinal dysraphism in a tertiary neurosurgical referral center
Kranthi Kumar, Suchanda Bhattacharjee, A. K. Purohit, B. P. Sahu, M. Vijaya Saradhi, A. Praveen, A. Rajesh, Madhukar Nayak
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India.
Spinal dysraphism still remains a complex diagnosis in pediatric neurosurgery. It occurs in various combinations. Surgery is the treatment and recovery may be complete or partial. We aimed to study the pattern of spinal dysraphism cases and their surgical outcome reporting to a tertiary neurosurgical referral centre. A retrospective analysis of two hundred cases admitted from January 2000 to January 2010 has been analyzed. Age group ranging from birth to 18 years, majority of the cases being tethered cord due to split cord malformations and previous surgery at an early age for any type of meningo or myelomeningocoele. The next frequently occurring was lipomeningocoele. Focal hypertrichosis correlated with 90% of split cord malformation. Other markers like dimple, low lying lipoma, gluteal cleft, dermal sinus, nevus are all seen. There was no mortality and minor post operative complications like CSF leak was seen in 10% cases. There was neurological deterioration in 5% cases. 95% cases was neurologically stable as pre operative status at the time of discharge. Trend of spinal dysraphism reporting to a neurosurgical centre in this part of the country has changed over the years. Fresh cases of myelomeningocoele are hardly seen here and the major burden is due to earlier operated cases at infancy now presenting with tethered cord at growth spurt. The surgical outcome correlates with those mentioned in literature.
8. Myelocystoceles: A retrospective study of 13 consecutive cases
Vivek Tandon, Kanwaljeet Garg, Ashok Kumar Mahapatra
India Institute of Medical Sciences, New Delhi, India
Objective: To analyse the clinical presentation, treatment, surgical complications and outcome in patients with myelocystocoele. Method: This is a retrospective analysis of 13 patients. All patients underwent neurological examination, plain x-ray films of the spine, computed tomography scans of the brain, and magnetic resonance (MR) imaging of the spine to confirm the diagnosis. Results: The mean age of the patient was 22 months (median = 3.0 mths), 10 (76.9%) were males. All of the patients with myelocystocele presented with swelling in the lower back and varying degrees of neurological deficits, weakness of lower limbs was the most common complaint in 12 (92.3%). In each of these cases, patients underwent excision of the meningocele sac and drainage of the syringocele with detethering of the spinal cord. Conus was low lying in 12 (92.3%), thickened filum was seen in 10 (76.9%), syrinx 4 (30.8%), chiari malformation and hydrocephalous in 2 (15.4%) each. Post operative CSF leak occurred in 2 (15.4%). During the last follow-up visit (range 3 mths-5 yrs), there was no change in the neurological status of these children, except one patient presented with increased neurological deficits; that patient had paraparesis with incontinence. During the follow-up period no patient presented with retethering. Conclusions: Myelocystoceles are dissimilar from other skin-covered masses of spine. A proper imaging evaluation is required to differentiate myelocystoceles from other lesions in this area, because the surgical treatment and prognosis may differ for these group of patients.
9. ETV: Analysis of causes of failure in pediatric population presenting with obstructive hydrocephalous: A KGMC, Lucknow experience
KGMC, Lucknow, India
ETV has become a common alternative for managing hydrocephalus in select patients However, endoscopic surgery in children has peculiar characteristics and is associated with different rates of success. In this study, the authors report on their experience with endoscopy procedures performed in 84 patients < 18 years of age and investigate factors related to ETV success or failure in this patient population. Between August 2008 and july 2010, 84 ETVs were performed in 84 patients with obstructive hydrocephalus at the authors' institution. The ages of the patients ranged from 6months to 18 years. Patients underwent prospective clinical follow up during a mean period of 17 months (range 6 month-26 months), The relationship between ETV efficacy and different variables were analyzed. Success of ETV was assessed based on the results of clinical evaluation during the follow-up period. Failure of ETV was defined as the subsequent need for shunt implantation or redo ETV. In our group of patients there was significant correlation between ETV success and different variables under study. Success Rate of Endoscopic third ventriculostomy performed at our institution will be discussed. Followed by analysis of factors probably contributing to ETV failure in the pediatric population under study.
Key words: ETV, hydrocephalous, failure*
10. Automatic Brain Segmentation in Epilepsy
A. M. Mohan Rao, T. R. Devendra, L. T. Kishore
LT Kishore Care Hospitals, Banjara Hills, Hyderabad, *Logic Medical Systems, Mehidipatnam, Hyderabad, India
3D-MRI imaging is routinely used to diagnose temporal lobe epilepsy (TLE) where amygdala and hippocampal atrophy are found. Automatic brain segmentation module of Slicer3 is used to obtain structures from 3D-MRI images (4 epilepsy, 2 normal, 1 tumor). A commandline segmentation is run on templates to obtain structures hierarchically. Parahippocampal gyrus, hippocampus and amygdala are obtained sequentially from (1) greymatter, (2) cerebral cortex and subcortical nuclei,(3) temporal lobe and limbic system. ACPC registration and label alignment are used to ensure model making of correct volume before segmented structures are converted to surface models. Size, shape and spatial relationships of hippocampus, parahippocampal gyrus and amygdala obtained from patient images are compared with controls (C). We use Slicer3 labelstatistics module to find volumes (mm 3 ) of amygdala and hippocampus: left amygdala (C=1822) 1461,1547,1551,1747; right amygdala (C=2030) 1588,1693,1657,1875; left hippocampus (C=5179) 3833,4104,3965,4578; right hippocampus (C=5010) 3829,4051,3914,4495. Our findings are in conformity with earlier reports that amygdala and hippocampal volumes are reduced in TLE. Their spatial relationship with neighboring parahippocampal gyrus is altered in TLE. These findings are shown in all orientations of amygdala, hippocampus and parahippocampal gyrus collectively. Clip sections of nuclei show nodularity and is earliest and progressive related to age (years:7,21,25,42). Replacement of smooth surface by nodularity is a key change of these structures in TLE. We suggest automatic segmentation of brain in TLE is useful additional tool to conventional studies.
Key words: Automatic segmentation, MRI image, Slicer3, epilepsy
11. Split Cord Malformation: 53 Cases, a two year experience at AIIMS
A. K. Mahapatra
All India Institute of Medical Sciences, India
Over a 2 year period, 2008-2009, a total of 53 cases SCM were treated at AIIMS. There were 30 cases of type I and 23 patients with type II SCM. Seven patients were above 18 years of age. Seven patients were asymptomatic. 13 patients had hypertrichosis, 4 had dermal sinus. Bony deformity of spine was recorded in 24 patients, of them 19 had scoliosis and 4 had kyphosis. Deformity of foot was recorded in 10 patients. MRI revealed syringomyelia in 14, with one having ACM. Six patients had MMC. Thick filum was recorded 10 and in another 9 there was filum Lipoma. Dermoid was encountered in 4 and only one had epidermoid tumor. Double split was noticed in 7 patients. Site involved was thoracic in 22, followed by Lumbar in 21. Only 3 patients had cervical Split. Seven patients had two separate splits. All patients underwent surgery. Seven patients, those who had no neurological deficit pre op, remain unchanged post op. Amongst the 46 patients those who had neurologic deficit 8 had deterioration post op, 5 had motor deterioration at 3 had urinary problem. However, among 8 those who deteriorated 4 improved up to preop status by the time of discharge. Overall SCM is a an uncommon condition. In all cases of progressive scoliosis MRI must be carried out. We subjected all asymptomatic patients to surgery and none developed post op deterioration. Overall deterioration was noticed in 15% of which 8% had transient post op deterioration.
12. Portable mobile computed tomography in neuro-trauma intensive care unit: Usefulness as a bedside intracranial morphological monitoring tool
Deepak Gupta, Shameem Ahmad, Ashok Kumar Mahapatra
Background: Transportation of unstable neurosurgical patients involves risks that may lead to secondary brain injury. Until recently,mobile computerized tomography (MCT), has not been available for bedside use. Objectives: To evaluate use of portable MCT scanner in the Neuro- ICU, to assess its feasibility, indications, time to perform, safety. Methods: Brain injured patients require multiple CTs / often hemodynamically unstable imposing risks on shifting out of ICU. The transport between NICU and CT suite takes 20-60 minutes. Clinical information of patients who underwent MCT were analyzed, rationale for the scan collected. Individual patient scans were reviewed in PACS, judged for diagnostic quality and compared with the baseline CT. Results: Total 1459 head MCT scans were done in NICU at our hospital. (July 2009 to May 2010). Diagnostic quality was adequate. No scans were complicated by accidental disconnection of an intravenous line. In ventilated patients, there were no interruptions in mechanical ventilation and no inadvertent extubations. Continuous ICP monitoring remained connected. Total time to perform a portable head MCT scan was 10 min, actual scan time being 2.5 min. Conclusions: Portable MCT scanner is feasible, easy to use, safe and provides adequate radiological quality for diagnostic decisions without shifting critically ill patients to CT scan room.
13. Role of neuroendoscopy in shunt malfunction in pediatric patients
G. Vidya Sagar
Narayana Medical College, India
Shunt malfunction is a common complication after shunt surgery. The common cause being shunt infection fallowed by shunt obstruction either at proximal or distal end and shunt migration. The distal end being in the abdomen it is easily amenable for revision where as the proximal end being in the ventricles it is always a blind procedure. Here we describe the method ofdiagnosis and treatment of shunt malfunction using rigid neuroendoscope. Forty eight cases of shunt malfunction who were treated with endoscopy were analyzed with respect to age and sex, procedures performed,clinical outcome morbidity and mortality. Twenty cases of aqueductal stenosis for which shunt has been done were submitted to endoscopic third ventriculostomy.Ten cases of univentricular hydrocephalus were treated with septostomy.Repositioning of shunt was done in eight cases.In five cases intraventricular cyst excision done and in another five cases no discernable cause can be found. Endoscopic third ventriculostomy was successful in relieving symptoms in 50% of cases. Septostomy was useful in all cases. Repositioning of shunt relieved symptoms in only in 2/3 0f cases. Intraventricular cyst excision was combined with shunt repair. One patient developed csf leak which was repaired and one patient developed meningitis which later subsided with antibiotics. There is no mortality with the procedure. To conclude neuroendoscopy is a valuable aid in the diagnosis and treatment of shunt malfunction.
Key words: Hydrocephalus, neuroendoscopy, shunt malfunction.
14. Clinico - imageological features- surgical outcome at short term in pediartic craniopharyngiomas
D. Jagadeeswara Reddy, B. Suchanda, B. P. Sahu
Nizam's Institute of Medical Sciences, Hyderabad, India
Childhood craniopharyngiomas are rare tumours that present formidable difficulties in their treatment if cure is to be achieved without producing severe hypothalamic damage. We have conducted a prospective study to evaluate the clinico-imageological features and their correlation to surgical outcome in pediatric craniopharyngiomas. In this study total 24 patients are included who undervent surgery and histopathologically confirmed as craniopharyngiomas.The age range was 1 yr to 20 yrs. 54% were males and 46% were females. Headache was the presenting complaint in 74% of patients and was associated with vomiting in 54% of total patients.Visual examination was near normal in 37% of the patients and 4% had no useful vision Diabetes Insipidus was noted in 25% of patients.58% of patients had no significant hormonal abnormality. Focal neurological deficits were present in 17% of patients. 29% of the patients were functionally independent. 30% of the patients had mild to moderate hypothalamic disturbances. Most of the tumours had solid and cystic components with evidence of calcification on CT scan.Vertical extent and size was assessed based on MRI.CSF diversion was done in 8 patients. Fronto-temporal craniotomy with subfrontal and transsylvian approach was the most common surgical approach used. Transphenoidal approach was used in one patient.Retromastoid suboccipital craniectomy was required in one patient because of extension of tumour into posterior fossa.Gross total resection was done in 33% of patients and subtotal resection was done in 67% of patients. During the post operative period D I and Electrolyte imbalance were the common problems and 7 patients required ventilator support. 4 patients expired in the post operative period. All tumours were adamantinomatous craniopharyngiomas.Mean follow up period was 17.4months. Visual improvement noted in 50% of patients and 62% were on hormonal supplementation. Increased B M I was noted in 32% of patients. 55% of the patients were functionally independent at the time of last follow up. Data was analyzed using SPSS software and found that raised icp, hypothalamic involvement, vertical extension of tumour is significantly associated with surgical morbidity and mortality.
15. The need for early surgery craniosynostosis
Raju Subodh, Lokesh Lingappa, Jaleel Ma, Dilnawaz B, Renuka, Sharan
Kamineni Hospitals, Hyderabad, India
Craniosynostosis refers to premature fusion of one or multiple sutures. Apart from obvious cosmetic facial and cranial deformity early closure of sutures can cause intracranial hypertension and affect neurodevelopment in some children. The over all Incidences of craniosynostosis is estimated 1 in 2000 live births. The awareness among general public and primary care pediatrician colleague regarding this potentially treated condition is still low. Usually parents and care givers are reassured about the deformity being corrected spontaneously with position and posture; but this is possible only in Deformational abnormalities and not true for craniosynostosis. We review our short series of 9 patients with various non syndronic craniosynostosis who underwent treatment and their outcome. A equal number of patients might not have undergone surgery because of lack of awareness or not convinced that this obvious cosmetic deformity can be a cause of concern at later date. In our series we had 4 cases of Anterior plagiocephaly, 3 cases of Trignonocephaly and 2 cases of scaphocephaly between ages 4-16 months. Early correction yielded better results because of malleability of bone and spontaneous correction with brain growth. Children with cranio synostosis require frequent medical evaluation to ensure that the skull and facial bones and brain are developing normally. The key to treating craniosynostosis is early detection and treatment.
Key words: Craniosynostosis, plagiocephaly, scaphocephaly, trigonocephaly, neurodevelopment
16. Endoscopic Treatment of Intracranial cysts in children Endoscopic Treatment of Intracranial cysts in children Endoscopic Treatment of Intracranial cysts in children
Rnuka Sharma, Raju Subodh, Lokesh l., Dilnawaz B., Jaleel M. A., Sharan B, Ravikant, Lokesh B. l., Shailender
Kamineni Hospital, Hyderabad, India
Key words: Neuroendoscope, arachnoid cyst, rathke's cyst, cystoventriculostomy The use of endoscope for various cranial procedures is gradually widening. Intracranial cystic lesions in the brain is one of the most attractive targets for this minimally invasive procedure thus avoiding a conventional craniotomy. These cystic lesions in brain namely arachanoid cyst, Rathke's cyst are congenital in nature. Surgical treatment for these depend on clinical presentation, location and age. We discuss 8 cases of Intracranial cyst aged between 4 months to 8 months. (6 Archanoid cysts & 2 Rathke's Cysts) operated between 2005-2009. Of these 6 Arachnoid cysts, 3 presented with abnormal increase in size of head, 2 presented with seizure (infantile spasm) and one was a large asymptomatic cyst. In 2 children cysts were diagnosed antenataly. Of the 2 Rathake's cysts one was diagnosed antenataly and 2 nd child presented with poor gaze fixation. Each of them underwent Endoscopic cystoventriculostomy and/ or cystocisternostomy with biopsy from cyst wall. Clinically and radiologically all children have improved with an average followup of 2 years. A symptomatic Intracranial cyst or a large asymptomatic cyst are indications for Neurosurgical intervention and endoscopy is a good treatment option with advantage of minimal invasiveness and less complication.
17. Factors affecting neurodevelopmental outcome in children with hydrocephalus
Raju Subodh, Dhananjay, Satyanarayana K., Dilnawaz B., Jaleel M. A., Renuka S., Ravikant
Kamineni Hospital, Hyderabad, India
V P shunt it is not uncommon for children with hydrocphalus to have delayed developmental milestones and some degree of learning difficulty. Those most often associated with hydrocephalus are delayed social, language, motor development, nonverbal learning disorder and difficulties in understanding complex and abstract concepts. This was a prospective study carried in 37 children less than one year of age. All the children underwent surgical treatment for hydrocephalus at our hospital, between the period March 2008 and November 2009 and are under regular follow up. All children are up to follow up minimum up to the age of 2 years. Trivandrum developmental screening chart was used in this study and Fisher's exact test is a statistical test used in analysis of this study. 25 patients underwent successful Endoscopic 3 rd ventriculostomy and 12 patient underwent successful VP shunt. Out of 37 children 5 (13.5%) had normal milestones at presentation and were normal postoperatively also. In the remaining 32 children with delayed milestones 20(62.5%) improved and in 12(37.5%) children delayed milestones persisted. Developmental outcome depends on etiology, duration of disease before treatment, associated CNS and other anomalies, time of diagnosis and treatment. Outcome was independent of type of procedure done (VP Shunt / ETV).
Key words: Hydrocephalus, neurodevelopment, 3 rd ventriculostomy,
18. Correlation of functional outcome and natural history with clinico-radiological factors in surgically managed pediatric Chiari I malformation
Furtado S. V., Thakar S., Hegde A. S.
Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India
The authors studied the clinical presentation and surgical outcome of pediatric Chiari I malformation and correlated the outcome with demographic and clinical factors and radiological changes in the syrinx, spinal cord and pre-operative intracranial, posterior fossa and foramen magnum dimensions. This study spanning 9 years included 22 symptomatic pediatric Chiari I patients, 20 of whom underwent foramen magnum decompression, shrinkage of tonsils and duraplasty. Clinical improvement at follow-up was assessed using a modification of the Asgari scoring system. Mean differences in the dimensions of the syrinx and cord, foramen magnum morphometry, intracranial and posterior fossa for 2 subgroups (those with improvement and those without improvement) were analyzed using the independent-sample Student's t test. Correlation of surgical outcome with demographic and clinico-radiological findings was evaluated using the Pearson's Chi-square test. Sixty percent of the study group showed functional improvement at follow-up. There was no difference in outcome in subgroups based on age, type of symptoms and their duration (P > 0.05 for difference in the subgroups). Of the various demographic and radiological factors assessed, there was significant difference in mean values of change in cord diameter for the entire cohort (P =0.05) and for another sub-group with pre-operative syringes (P = 0.029). There was no correlation between change in any of these factors and functional improvement (χ2 range, 0 to 4.673, P > 0.05). More than half the pediatric patients with CMI improve after surgery. The age at presentation, duration and type of symptoms, cranial and foramen magnum morphometry and syrinx-related changes have no bearing on outcome at short-term follow-up. The spinal cord diameter differs significantly in patients with and without functional improvement.
19. Neoplastic vertebral lesions in children: A 10 year Institutional experience
Rajeev Sharma, Jagath Lal, B. Indira Devi, S. Sampath, B. A. Chandramouli
National Institute of Mental Health and Neurosciences, Bangalore, India
Introduction: Neoplastic vertebral lesions in pediatric population are rare, with vertebral involvement being primary or secondary. Aims and Objectives: To study the presentation, management, and outcome of neoplastic vertebral lesions in pediatric population. Material and Methods: All paediatric patients treated in NIMHANS during the period 2000- 2009 were included in this retrospective analysis. All these patients had undergone tumor excision/ decompression, except one patient who underwent FNAC only and diagnosis was confirmed histopathologically. A detailed proforma analysing the diagnosis, clinical features, surgical findings, and follow up data was developed. A review of radiological findings and histopathological slides was done. Results: 30 patients (male 18, female 12) were included in this study. Majority of patients presented with local spinal pain and neurological deficits. Malignant (n = 19) lesions were seen more commonly in this series than benign (n = 11) lesions, the pathology being peripheral primitive neuroectodermal tumor (n = 6), Ewing's sarcoma (n = 5), non hodgkin's lymphoma (n = 4), chordoma (n = 1), squamous cell carcinoma (n =1), metastasis (n = 1), osteoblastoma (n = 1). The most common benign lesions were osteochondroma (n = 4), and hemangioma (n = 4). Details of surgical management, adjuvant therapy, and outcome are discussed. Conclusion: Neck or back pain in pediatric population has to be considered with a high degree of suspicion and thus needs to be investigated more diligently. Diagnosis before development of neurological deficits and good surgical decompression are the key factors for good outcome.
Key words: Neoplastic vertebral lesions, pediatric
20. Endoscopic third ventriculostomy intraop-erative complications
T. V. Ramakrishna Murty, Syed Ameer Basha, T. N. Rao
Care Hospitals Hyderabad, India
Endoscopic third ventriculostomy has been shown to be an alternative treatment in the surgical management of obstructive hydrocephalus. We analyzed our series of 56 patients who underwent ETV for various conditions. 48 of them underwent ETV for acqueductal stenosis, 4 for tumours in posterior third ventricular region and 4 for communicating hydrocephalus. We concentrated our analysis to the difficulties we faced during the operative procedures. Procedure was abandoned in four patients. In one patient the procedure was abandoned because of venous bleeding and in three others it had to be abandoned because of abnormal anatomy and inability to identify the mamillary bodies. In two patients the space between the basilar artery and the dorsum sella was insufficient for making a stoma resulting in failure of the procedure. Abnormal position and tortuosity of the basilar artery resulted in an insufficient stoma in one patient. In two patients there was a second membrane (Lillequist's membrane) obstructing the smooth flow of CSF. In two patients the membrane was abnormally tough and we had to resort to alternative measures to make the stoma. We feel that when ETV is mixed with biopsy of an intraventricular lesion it is preferable to do ETV first followed by biopsy. There was no mortality in our series.
21. Short Term Outcome in Children with WHO grade 3 Supratentorial Anaplastic Ependymoma
Kartik Revanappa Kumbhar, Ranjith Moorthy,
Christian Medical College, Vellore, Tamil Nadu, India
Aim: To study the short term outcome in children with supratentorial anaplastic ependymomas WHO grade III. Materials and Methods: Nine patients underwent surgery for supratentorial anaplastic ependymoma WHO grade III between December 2003 and September 2010, of whom seven patients received postoperative adjuvant radiation therapy. Six of these patients were available for follow up. Results: The mean age of presentation was 10.4 years (range, 1-16 years). The mean duration of follow up was 16.8 months (range 4-48 months). Seven patients underwent radical excision while one patient each underwent biopsy and partial excision of their tumours. Five of the seven patients who had radical excision of their tumours received postoperative conventional radiation therapy. Of the patients available for follow up, one patient who had radical excision with no postoperative radiation therapy developed an asymptomatic recurrence at one year follow up. Two children developed postoperative aseptic meningitis. There was no death in our series. Conclusion: The recurrence rate following radical excision of supratentorial anaplastic ependymomas with or without postoperative radiation therapy is low at a short term follow up of 16.8 months.
22. Clinico imageological and surgical out comes in Paediatric atlanto axial dislocations.
Chandrasekhar Y. B. V. K., Praveen A., Saradhi M. V., Suchanda B., Sahu B. P., Purohit A. K.
Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
This study was conducted to evaluate the outcome in various operative techniquesof paediatric AAD patients. 30 patients diagnosed as AAD who underwent surgery at Nizams Institute of Medical Sciences, Hyderabad were analyzed retrospectively between June 2004 to April 2010. Details were taken from neurosurgical discharge summary database and operation theatre records. There were 21 males and 9 females. Age range was from 6 to 18 years. The etiological classification was divided as 19 congenital, 8 traumatic, 2 CVJunction tuberculosis and a single case of rheumatoid arthritis.14 were reducible 16 were irreducible. In this group 5 patients were managed conservatively and 25 underwent surgery. 8 patients underwent combined trans oral and posterior fixation, 15 patients underwent only posterior fixation and 1 patient only anterior approach trans cervical trans articular screw and 1 patient underwent subtotal resection of granulation tissue without fixation by posterior approach. Among the posterior fixation patients 11 patients underwent occiput to C2 fixation, 3 patients underwent occiput to c2 &c3 fixation, 8 patients underwent c1 c2 sublaminar wiring, 1 patient underwent trans articular screw fixation, 1 patient underwent c1 c2 lateral mass screws, 2 patients underwent c1c2 distraction technique and 3 patients underwent combined posterior approaches [sublaminar wiring and OC2 and sublaminar wiring and OC 2C3]. There were 2 cases of mortality in our series of 30 patients. Implant failure was encountered in 3 cases and a transient wound infection in one patient. Follow up ranged from 3 months to 5 years and is avaible in 80% of patients all of whom significantly improved.In conclusion AAD in paediatric age group is curable and has good prognosis when properly analyzed and correctly fused and gives good surgical outcome.
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1. Management of Giant ICA aneurysm
Chinmay Bhalke, Kumar Pranav, Harsh Bhargav
Indraprastha Apollo Hospital, New Delhi, India
Cerebral revascularization is an important modality of management in select patients with aneurysms that associated with complicated outlook due to size, shape, location, intramural thrombus, atherosclerotic plaques, aneurysm type (for example, dissecting aneurysms), vessels arising from the dome, or poor collateral vascularization when parent artery or branch occlusion is required. These techniques,which were first successfully described by Yasargil in the late 1960s, are used to prevent cerebral ischemia and further demage. Bypass techniques should be considered in cases in which occlusion test suggest inadequate cerebral blood flow with or without collaterals and in which there is need for ligation, trapping, or prolonged temporary occlusion of the affected vessel. Under consideration is a case of 14 yr old child who presented with acute onset weakness in right half of the body 3 months before coming to the center. He was investigated for and found to have an ectatic Left ICA from origin till 1 st division of Left MCA and abnormal left anterior circulation. A combined (neurosurgical + endovascular) approach was taken for augmentation of the blood supply to Left half of the brain and obliteration of the ecstatic vessel with favorable outcome. In presentation we discuss about the less commonly used bypass technique, its development through different phases of neruosurgical history to recent techniques of using hemodynamic studies and ELNA.
2. Is tissue diagnosis essential?
Kalyan Bommakanti a , Manas Panigrahi b , Jyotsna Rani Yarlagadda c , Sundaramd, Megha S. Uppin d , A. K. Purohit a
a Department of Neurosurgery, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, b Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, c Department of Radiology & Imageology, d Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India
Background : Optic pathway gliomas account for approximately 5% of brain tumors in children. Their management is controversial, with a few instituting primary radiotherapy or chemotherapy without a biopsy confirmation and others confirming the lesion by biopsy and histopathological examination before starting radiotherapy or chemotherapy. Methods : The MR images of 25 patients with either histologically proven optico-chiasmatic-hypothalamico "pilocytic astrocytoma" or radiologically suspected optico-chiasmatic gliomas are analyzed and the imaging characters described. The rationale of instituting various modalities of treatment without a histopathological confirmation is discussed. Results : A total of 25 patients were included in the study. On the basis of radiological features, the patients were divided in to three groups. Group I lesions were solid tumors with or without microcysts. Ten patients were categorized in to this group. Nine of them were pilocytic astrocytomas and one was a tuberculoma, as confirmed by histopathological examination. Group II gliomas are mixed tumors with solid and cystic components. Nine patients had this radiological pattern and among them 7 were biopsy proven gliomas and 2 were craniopharyngiomas. The remaining six patients included in group III had ring enhancing lesions. They were all initially treated as tuberculomas. In three patients the lesion resolved and the remaining three were subjected to biopsy. The histology was suggestive of pilocytic astrocytoma in these three. Thus, MRI has a sensitivity of 84.2% and a specificity of 50% for diagnosing optico-chiasmatic gliomas.
Conclusions : Various lesions like craniopharyngiomas, tuberculomas can mimic optico-chiasmatic gliomas radiologically and it is not possible to diagnose them with certainty on radiological grounds alone. Biopsy and tissue diagnosis should always be sought before instituting radiotherapy or chemotherapy for optico-chiasmatic gliomas. Key words: Pilocytic astrocytoma; optico-chiasmatic glioma; hypothalamic glioma; suprasellar; optic pathway gliomas.
3. Confusion in adult spinal dysraphism; Type 1c Vs 1d SCM
Noufal Basheer, Hitesh Gurjar, A. K. Mahapatra
The level of splitting and the extent of the spur is different in cases of Type 1 SCM. Surgery must be planned meticulously according to the SCM Type I subtype in order to prevent neurological deterioration. A Thirty five year old male patient presented with back pain and paresthesia of bilateral feet of 3 year duration. His MRI showed type 1 SCM with low lying cord ending at L5 level. He undergone L1 - L5 laminectomy.He had 2 hemicords straddling the bony spur prior to opening the dura (Type 1d ) and was type 1C on opening the dura with large duplicated cord above. Type Ic cases warrant dissection and removal of the spur from above the split because the space below it is narrow and chances of injury to the cords are high if an attempt is made to dissect from below. So opening of dura and visualization of position of the spur is important. The subclassification of SCM Type I, based on the location and extent of the bone spur is important from a surgical point of view so that neurological deficits can be avoided.
4. Suprasellar cavernous angioma of a neonate: Case report and literature review
Udayakumaran S., Paraskevopoulos D., Roth J., Constantini S.
Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv University, Tel Aviv, 64239, Israel
Cavernous angiomas (CA) are congenital intraparenchymal vascular malformations. Despite the congenital origin of CA, they rarely present in the neonatal and prenatal period. In this paper, we present a case report of a neonatal suprasellar CA that presented with a bleed. We also present a literature review focusing on specific features of intracranial CA in the neonatal and fetal age groups. A 27-day-old neonate presented with a left eye ptosis for 2 days, followed by a generalized seizure. A head computed tomography revealed a suprasellar hematoma with intraventricular and subarachnoid extension. Brain magnetic resonance imaging revealed hemorrhages of various ages with no evidence of vascular malformation on angiography. Surgical exploration of the suprasellar mass revealed a capsulated dense hematoma. Pathology revealed a CA. CA presenting as a suprasellar bleed with subarachnoid and intraventricular extension is very rare especially among neonates. To the best of our knowledge, 20 cases of CA have been reported in the neonatal and fetal period in the English literature. Neonatal CA in general and suprasellar location in particular are extremely rare lesions. Neonatal/fetal CA seems to present more aggressively and have a worse prognosis compared to those presenting at a later age.
Keywords: Neonatal Intracranial bleed, Cavernous angioma, Suprasellar bleed, Neonatal seizure
5. Isolated metastasis to cervical spine from occult thyroid carcinoma mimicking Aneurysmal Bone Cyst in an adolescent male.
Rajesh Reddy S., Suchanda B., Megha Uppin S., Sundaram C., Raju G. S. N., Prabhakar V. V. S.
Nizam's Institute of Medical Sciences, India
Spine metastasis due to malignancy from the thyroid is rare in the pediatric age group. Still rarer is the metastasis from a follicular variant of papillary carcinoma. In contrast, aneurysmal bone cysts are known to occur predominantly in the younger males. We present an adolescent male who presented with cervical compressive myelopathy due to cervical spine metastasis from an 'occult' thyroid malignancy which was a follicular variant of thyroid carcinoma. The radiological features of spinal metastasis from thyroid cancer and aneurysmal bone cyst are discussed. A follow up of the case and a brief review of literature pertaining to the case under discussion is also provided.
6. Role of tumor markers in diagnosis and management of pineal region tumors
R. Srinivasa Rao, Manas Kumar Panigrahi, B. P. Sahu, A. K. Purohit
Introduction: Germ cell tumors are highly sensitive to radiotherapy and chemotherapy and account for more than fifty percent of pineal region tumors. Aim of this presentation is to evaluate role of tumor markers in diagnosis and management of pineal region tumors. Methods: Nine paediatric patients with pineal region tumors admitted over the past three years were analysed. Tumor marker (AFP, β-HCG and CEA) analysis of CSF and serum as well as CSF for malignant cytology were done for all. They were divided into two groups depending on CSF tumor marker levels. Group l: (elevated tumor marker levels) were treated with direct radiotherapy or chemotherapy without histopathological confirmation. Group ll: (insignificant tumor marker levels) were treated with definitive surgery / biopsy followed by radiotherapy or chemotherapy as necessary. Initial CSF analysis for tumour markers was done in control population to establish normal values in local population Results: Group l: Four patients had elevated tumor marker levels, of which two patients were referred for direct radiotherapy and two for direct chemotherapy. Second look surgery was done for one patient, for which HPE revealed pinealoblastoma. Group ll: Five patients had insignificant tumor marker levels. Surgery was done in three patients and all of them were pinealoblastomas. One patient was put on ATT based on imageological characteristics and another patient under observation as there was benign pineal cyst imageologically. Conclusions: Tumor marker study is useful to differentiate germ cell tumors from nongerm cell tumors of the pineal region.
7. Cervical dermal sinus complicated with intramedullary abscess in a child: Case report and literature review
A. De Tommasi, A. Calace, Nunzio Bruno, N. Zelletta, Floriana Sardelli, G. Occhiogrosso
University of Bari, Italy
Dermal sinus tract (DTS) is an uncommon spinal dysraphism presenting in childhood. DST has been reported along the midline neuroaxis, from the occiput down to the lumbar and sacral regions, more frequently occurring in the lumbo-sacral tract. Cervical localization of the DST is rare. Exceptional is its association with intramedullary abscess through cutaneous fistula. A 9 month old baby was admitted to our Unit suffering from right hemiparesis. Physical examination showed a cervical midline cutaneous fistula dripping a yellowish thick liquid. Cervical MRI showed at C5 level a sinus tract in continuity with a C3 - C6 intramedullary lesion. The patient underwent surgery with isolation of the fistula followed by C3 - C6 laminectomy. Opened the dura around he deep fistula, the arachnoid appeared thickened and adhered to a intramedullary neoformation communicating with the dermal sinus. Total removal of the fistula and the intramedullary lesion was performed. Histopathological examination confirmed the diagnosis of dermal sinus and abscess. Post-operative cervical MRI showed a complete removal of the spinal dysraphysm, fistula and intramedullary abscess. The baby showed a progressive improvement of right hemiparesis. The post operative course was without complications and the baby was discharged on day 10 post-surgery and addressed to a neuro-rehabilitation Center. Cervical dermal sinus associated with intramedullary abscess is extremely rare. The literature review confirms that an early diagnosis, mostly a prompt surgical intervention, give chance of a good functional neurological recovery. Key words : cervical dermal sinus, intramedullary abscess, spinal dysraphism.
8. Case of intra abdominal ganglioneuroma with intraspinal extension
Muralikrishnan V. P., Anilkumar P.
3 year old girl presenting with difficulty in walking whose imaging showed a large mass in the paravertebral region from D12 to L4 displacing the kidney and extending into the lumbar spinal canal to extend extradurally from D11 to L3. The child was operated upon by osteoplastic laminotomy total excision of intraspinal lesion and laminoplasty done. histopathology of lesion was ganglioneuroma. on follow up motor power improved. ganglioneuroma presenting as intrabdominal swelling with intraspinal extension is rarely reported.