[Medulloblastoma in children. Current treatments and future perspectives]

The various treatments currently available for medulloblastoma are reviewed and modifications which have occurred over the last ten years are analyzed. Surgery is the first step of the treatment of a medulloblastoma. Recent advances in neurosurgical anesthesia and intensive care have substantially improved the quality and extent of exeresis and markedly reduced operative mortality (currently under 2%). Radiotherapy of the entire central nervous system should follow surgery in every case. Use of high energy radiations (together with improvements in surgical treatment) have increased survival rates to 50-60%. However, side effects are frequent. The modalities and timing of chemotherapy have also changed considerably over the last ten years; the different modalities currently used are reviewed, as well as the strategies available for reducing toxic effects and hematologic complications. Currently, chemotherapy is "sandwiched" between surgery and radiotherapy. Treatments under evaluation (monoclonal antibodies, immunotoxins, and immunomodulation) are discussed. The purpose of this therapeutic strategy for medulloblastomas is not only to increase survival rates but, above all, to improve the quality of life in survivors. Close cooperation between health care professionals of the different specialties involved and long term multicenter studies are indispensable if this goal is to be achieved.

[Meningeal hemorrhage disclosing a brain tumor in a child]

The case of a 14-year-old girl who had severe subarachnoid bleeding as the first manifestation of a benign astrocytic tumor of the lateral aspect of the third ventricle is reported. Tumors that cause bleeding are usually neuroectodermal tumors in children and malignant tumors in adults. A review of the literature serves as the basis for a discussion of the frequency of bleeding as the first manifestation of brain tumors (1 to 10%) and of the pathogenesis of these hemorragies for which three theories (vascular, mechanical, and metabolic) have been put forward.

Skull base in trigonocephaly

The authors present aspects of the skull base in trigonocephalic children. Different patterns on clinical anthropometric investigation, bidimensional computer tomography (CT) scan and three-dimensional (3D) CT scan were studied. We present a series of 27 cases of trigonocephaly operated on in the department of pediatric neurosurgery at the Hôpital des enfants La Timone in Marseille since 1975. The skull base has been studied with CT scan in 12 patients and in 5 a 3D CT reconstruction was performed. A control series of 27 children without synostosis has been studied with the same patterns. We have analyzed in 3D, the volume of the anterior fossa related to the orbital volume, the permeability of basal sutures and the spatial orientation of petrous, sphenoid and zygomatic bones. An analysis of nasoethmoidal complex was performed in relation with hypotelorism. CT scan allows the study of the opening of orbital, nasion-pterional angles and the clinopterional angles, as well as nasion-clinoidal and bipterional distances. A computerized analysis of these data compared with normal skull base permits a new approach to these malformations and the necessity for subdivision of trigonocephaly.

[Arteriovenous malformations in children. A series of 61 cases]

A series of 61 cases of cerebral arteriovenous malformations(AVM) was observed in children under 15 years of age during the last 18 years; 7 concern infants under 12 months and more than 50% are children between 10 and 15 years old. Intra-cerebral hemorrhage was revealing in 45 cases (7.7%) and 12 patients were in comatose state at presentation; 8 children (1.1%) only presented epilepsy alone; 53 cases (86.8%) were operated upon and only one has had a partial removal; 2 children were cured by stereotactic radiosurgery; one child must be embolize and 5 children were not treated; 50 cases (82%) have a good or an excellent result with normal life; 7 cases (11.5%) have sequellae and only 4 children (6.5%) died.

Choroid plexus tumours in children. Review of 24 cases

24 cases of choroid plexus tumours (16 papillomas and 8 carcinomas) were observed in the Department of Paediatric Neurosurgery, Hôpital des Enfants de la Timone, Marseille France between 1975 and 1989. The case records were reviewed and the clinical, surgical, and pathological results are presented here. 14 (58%) were infants and 10 (42%) of these were aged less than 1 year at presentation. In 11 (46%) the tumour arose in the lateral ventricle, in 7 (29%) it was located in the IIId ventricle, and in 6 (25%) the tumour was found in the IVth ventricle. 5 of the 8 carcinomas had their origin in the IVth ventricle. 17 cases (75%) required ventriculo-peritoneal shunt procedures before surgery of the tumour and in all these it was left in place post-operatively. One child required shunting de novo after removal of the tumour. A total excision was achieved in 20 children (83%) out of 23 operated upon. The operative mortality (mortality within one month of surgery) was 8%, the overall mortality was 25%. One child with a IIId ventricle papilloma died before surgery from a large gastro-intestinal haemorrhage. 5 children under the age of 3 years with carcinomas on the IVth ventricle died. The 3 children with supratentorial carcinomas are alive respectively 2 months, 8 years, and 13 years after treatment. Among 15 children with papillomas alive, 10 (67%) are neurologically intact and 5 (33%) have sequelae.

Extradural haematoma in infants

The clinical and operative findings of 40 infants treated for Extradural Haematomas (EDH) between 1960 and 1988 are presented. This series represents 19% of the total number of children with EDH during this period. Twenty-five (63%) were male, fifteen (37%) female. They were divided into three groups according to age for comparison. Group A, less than 6 months (11 cases); group B, 7-12 months (16 cases); and group C, 13-24 months (13 cases). Sixteen (40%) resulted from falls less than 1 m. Seven (17.5%) fell whilst walking. Twelve (30%) fell more than 1 m. Two EDH followed obstetric trauma, three occurred as a result of a road traffic accident. A lucid interval was identified in 30 cases, and in 15 it was longer than 24 h. Drowsiness (60%), and delayed vomiting (45%), were the most important symptoms. Anaemia occurred in 19 (47.5%). Thirty-six (90%) had abnormal skull X-rays. Thirty (75%) EDH were parietal, temporal, or temporo-parietal. Two were located in the posterior fossa. There were no frontal EDH in this series in contrast to that found in older children. Twenty-seven (67.5%) EDH were larger than 75 cc in volume. The source of bleeding was identified in 31; in 17 (42.5%) it was from the middle meningeal artery; in 11 (27.5%) from the bone; and in three (7.5%) from the dural surface. The mortality was 12.5% with a 15% morbidity rate, three infants (7.5%), suffering motor deficits, and three requiring medical treatment for epilepsy.