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A critical comment on fourth ventricular tumor surgery performed in emergency versus electively: How does it differ?

1 Department of Neurosurgery, B.J.Wadia Children’s Hospital, Mumbai, Maharashtra, India
2 Department of Neurosurgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Submission09-May-2021
Date of Decision24-Sep-2021
Date of Acceptance08-Aug-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Sonal Jain,
Department of Pediatric Neurosurgery, B.J.Wadia Children’s Hospital, Parel, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpn.JPN_64_21


How to cite this URL:
Jain S, Deopujari C. A critical comment on fourth ventricular tumor surgery performed in emergency versus electively: How does it differ?. J Pediatr Neurosci [Epub ahead of print] [cited 2023 Sep 26]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=350289

The authors have reviewed eight-year data on 141 children evaluating surgical outcomes for fourth ventricular tumors in operated in emergency versus electively.

They have reported a higher incidence of emergency surgery for medulloblastoma in younger patients, more use of preoperative ventriculo-peritoneal (VP) shunt surgery and more postoperative wound complications, while better survival seen in children operated in elective settings.

We need to consider certain points before drawing these conclusions. The diagnosis of posterior fossa tumors is more challenging in the younger population, and their pathological behavior is notably worse.

The majority of fourth ventricular tumor surgeries are really not elective surgeries. They can be best called prioritized planned surgeries. It is important to have an appropriate protocol are the availability of a dedicated operating room (OR) (similar to elective surgeries) with trained personnel and the operating surgeon himself. This may be considerably different in emergency settings compared with elective circumstances in some institutions or on certain days.

Progressive cerebrospinal fluid (CSF) pathway obstruction, acute tumor bleed, tumor cyst expansion with subsequent hydrocephalus, peritumoral edema leading to brainstem dysfunction, and tonsillar herniation in the setting of fourth ventricular tumors warrant emergent management. In the wake of acute decompensation, the brain fails to adapt and the patient rapidly deteriorates. Respiration and cardiac rhythm affection are terminal events. In such circumstances, the lack of preoperative optimization, the missed chance of using neoadjuvant therapy in certain tumors, and the limited evaluation of the craniospinal axis with preoperative imaging are the downsides of emergency surgery.

There is no level I evidence available to dictate management protocols for fourth ventricular tumors in emergency or elective settings. Although some propagate optimization of preoperative status of the patient, others encourage attacking the tumor first whenever feasible.

One of the immediate measures taken by many surgeons is emergency CSF diversion. The means to manage hydrocephalus vary from endoscopic third ventriculostomy (ETV)[1],[2] to shunts to external ventricular drainage (EVD). The cited benefits of preoperative management of hydrocephalus are the better preoperative neurosurgical status of the patient before tumor surgery, time to deal with the tumor electively to everyone (patient’s brain, body, surgeon, OR, and the family), less incidence of postoperative CSF leak, and wound issues.

Preoperative permanent CSF diversion in the form of ventriculo-atrial shunt was first advocated by Abraham et al., and later, VP shunt was practiced with a view to optimize many of these patients who were admitted in moribund condition.[3] Chumas and Sainte Rose advocated ETV.[4] It still remains controversial as the majority of patients with fourth ventricular tumor resection do not require CSF diversion in the postoperative period.[5] Subjecting almost 70% of these patients to a procedure they might not actually need is questionable.[6] The EVD enthusiasts mention that EVD helps in clearing out the postoperative blood products, can be titrated, and gives a better idea of the intracranial pressure in the perioperative period. The downsides of a preoperative EVD are risks of reverse herniation, and we, therefore, prefer using it as immediate preprocedure after anesthetizing the child for definitive posterior fossa surgery.

Direct tumor surgery, on the other hand, facilitates tumor removal using the CSF in the subarachnoid cisterns as the buffer while operating.[7]

We believe that the tumor should be resected first whenever feasible and use EVD when necessary, before tackling the tumor, but may be worthwhile to keep an EVD at the end of surgery, till the child is stable and postoperative scan is performed to confirm opening up of the fourth ventricle.[8]

Given a variegated patient, tumor, and surgeon factors, it is difficult to stratify and subsequently standardize the management of fourth ventricular tumors. This study is meritorious in being a step toward identifying the problems and creating management protocols depending on associated hydrocephalus and peritumoral edema and level of brainstem involvement apart from the clinical condition of the child.



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   References Top

Di Rocco F, Jucá CE, Zerah M, Sainte-Rose C. Endoscopic third ventriculostomy and posterior fossa tumors. World Neurosurg2013;79:S18.e15-9.  Back to cited text no. 1
Fritsch MJ, Doerner L, Kienke S, Mehdorn HM. Hydrocephalus in children with posterior fossa tumors: role of endoscopic third ventriculostomy. J Neurosurg 2005;103:40-2.  Back to cited text no. 2
Abraham J, Chandy J. Ventriculo-atrial shunt in the management of posterior fossa tumors. Preliminary report. J Neurosurg 1963;20:252-3.  Back to cited text no. 3
Chumas P, Sainte-Rose C, Cinalli G . III Ventriculostomy in the management of posterior fossa tumors in children. Proceedings of the ISPN Congress, Santiago, Chile, 26–29 September 1995. Childs Nerv Syst 1995;11:540.  Back to cited text no. 4
Tamburrini G, Pettorini BL, Massimi L, Caldarelli M, Di Rocco C. Endoscopic third ventriculostomy: the best option in the treatment of persistent hydrocephalus after posterior cranial fossa tumour removal? Childs Nerv Syst 2008;24:1405-12.  Back to cited text no. 5
Sainte-Rose C, Cinalli G, Roux FE, Maixner R, Chumas PD, Mansour M, et al. Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy. J Neurosurg 2001;95:791-7.  Back to cited text no. 6
Goel A. Tumour induced hydrocephalus and oedema: pathology or natural defence. J Postgrad Med 2002;48:153.  Back to cited text no. 7
[PUBMED]  [Full text]  
Tamburrini G, Pettorini BL, Massimi L, Caldarelli M, Di Rocco C. Endoscopic third ventriculostomy: the best option in the treatment of persistent hydrocephalus after posterior cranial fossa tumour removal? Childs Nerv Syst 2008;24:1405-12.  Back to cited text no. 8


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