Concurrent pineoblastoma and unilateral retinoblastoma: a forme fruste of trilateral retinoblastoma?

A 10-month-old boy who presented with strabismus and symptoms of intracranial hypertension was found to have a pineoblastoma and a unilateral ocular retinoblastoma. Despite enucleation of the eye, subtotal removal of the pineoblastoma, and craniospinal axis irradiation, the patient died 6 months later from disseminated intracranial neoplasm. As there was no clinical evidence of bilateral retinoblastoma, this case may represent a forme fruste of the trilateral retinoblastoma complex. The clinicopathological features of this unusual syndrome are reviewed.

Intracranial pressure changes in arrested hydrocephalus

Continuous intracranial pressure (ICP) monitoring was used to assess 46 children and adolescents in whom a clinical diagnosis of arrested hydrocephalus had been made. Thirty patients (Group A) had previously been treated with cerebrospinal fluid diversion and 16 patients (Group B) had no prior treatment of their hydrocephalus. All patients in Group A either had a confirmed nonfunctioning shunt or had undergone shunt removal. Continuous ICP monitoring showed that 80% of the patients in Group A and 63% of those in Group B had episodic or persistent intracranial hypertension. In four patients (25%) whose initial ICP had been normal or equivocal, repeat ICP monitoring later revealed decompensation or reversal of arrest. When serial psychometric testing demonstrated a fall in cognitive functioning, ICP monitoring revealed abnormal ICP's in 88% of patients. This study shows that many patients with apparent arrest of hydrocephalus in fact have an insidiously progressive disorder. Monitoring of ICP and serial psychometric evaluation are therefore valuable tools in the continuing assessment of arrested hydrocephalus.

Intra-operative spinal cord monitoring during surgery for scoliosis using somatosensory evoked potentials

The method of intra-operative monitoring of spinal cord function by spinal somatosensory evoked potentials (SEP), as used at the Royal Alexandra Hospital for Children during surgery for scoliosis is described. Using a non-polarisable platinum spinal epidural electrode, SEP elicited by tibial and peroneal nerve stimulation in the popliteal fossa are recorded proximal to the level of spinal correction. The large amplitude and discrete waveform of the SEP enable rapid signal acquisition and easy interpretation. The spinal SEP is stable under both therapeutic hypotension and general anaesthesia. Electrophysiological monitoring has now superceded the 'wake-up' test as an index of spinal cord function during corrective surgery for scoliosis.

The arrest of treated hydrocephalus in children. A radionuclide study

A prospective study was made of the incidence of arrest of treated non-neoplastic hydrocephalus in 30 neonates and infants over a 5-year period. Radionuclide assessment of shunt function and cerebrospinal fluid (CSF) dynamics was carried out at intervals over this period, using a method that allowed injection of the radionuclide into the ventricular system independent of the shunt apparatus. The radionuclide scanning results were correlated with computerized tomography and clinical findings. Of 24 patients still available for analysis at the end of 5 years, four patients showed restoration of CSF circulation independent of the shunt apparatus and, in three of these, the shunt has either been clipped or clipped and removed without any ill effects. Clinical details of these three patients are provided. Two initially had communicating hydrocephalus, and one had probable aqueduct stenosis.

Progesterone and oestrogen receptors in meningiomas: biochemical and clinicopathological considerations

Specific progesterone and oestrogen receptor proteins were evaluated by a dextran coated charcoal assay and Scatchard plot analysis in 20 intracranial meningiomas. Eleven tumours (55%) were progesterone receptor (PR) positive (mean 108 fmol/mg cytosol protein), whilst all were oestrogen receptor (ER) negative (ER less than 10 fmol/mg cytosol protein). There were no trends to suggest a relationship between epidemiological data (patient age, sex and reproductive status in females) or meningioma location and size and the receptor status of the tumour. However, of the seven meningiomas that were histologically atypical, invasive or clinically recurred within 18 months, six were PR negative (PR less than 10 fmol/mg cytosol protein). These results confirm that a large proportion of intracranial meningiomas contain significant amounts of specific PR protein and suggest that PR negative meningiomas are biologically more aggressive than PR positive meningiomas. They are also consistent with the hypotheses that PR proteins are not modulated by oestrogens acting through oestrogen receptors and that there are cytokinetic differences between sex hormone receptor proteins in meningioma and breast carcinoma. The full biochemical, cytological and clinical implication of these preliminary findings will, however, require further evaluation because of the unpredictable long-term behaviour of intracranial meningiomas.

Intracranial pressure changes in craniostenosis

Intracranial pressure changes occurring in patients with craniostenosis were studied by continuous monitoring of intracranial pressure in 20 children. Although clinical or radiologic evidence of intracranial hypertension was present in only one patient, 13 (65%) had persistent or episodic raised intracranial pressure. Intracranial hypertension occurred with involvement of both single and multiple sutures and in four of six patients with hydrocephalus and craniostenosis. Recordings after surgical treatment in nine patients revealed that several months elapsed before intracranial pressure improved significantly or returned to normal, despite apparently adequate bony decompression. This study confirms that continuous monitoring of intracranial pressure adds significantly to clinical assessment in determining the need for, and the efficacy of, surgical treatment in craniostenosis.

Giant intracranial aneurysms: diagnosis, management, and outcome

The diagnosis, management, and outcome of a consecutive series of 25 patients with giant intracranial aneurysms are presented. Symptoms and signs directly or indirectly attributable to the intracranial mass effect accounted for presentation in 16 (64%) patients of whom seven had no focal neurological deficits. Nine patients (36%) presented after subarachnoid hemorrhage. Subarachnoid hemorrhage was frequently associated with intraventricular or intracerebral hemorrhage, a poor clinical grading at admission, and a high mortality (67%). Computed tomographic features of the giant aneurysms were usually characteristic; however, angiography was particularly useful in those in close proximity to the skull base. Nineteen patients had a surgical procedure directly or indirectly aimed at obliteration, isolation, or reinforcement of the giant aneurysm. Successful surgical obliteration or occlusion was obtained in 12 (63%) patients, while seven (37%) had only reinforcement or exploration of the aneurysm. The mortality associated with definitive surgical treatment was 5.6%, and major morbidity occurred in 17%. The good long-term outcome in 75% of the patients after occlusion of the giant aneurysm contrasted with the continuing mortality (43%) and morbidity (43%) in those patients in whom surgical obliteration of the aneurysm was not attained. Although advances in microsurgical instrumentation, anesthetic techniques, and innovative revascularization procedures have facilitated the surgical management of giant aneurysms, significant improvement in the high overall mortality associated with these aneurysms (36% in this series) will probably only be attained by diagnosis of giant intracranial aneurysms before they bleed.

Spinal cord monitoring during surgery by direct recording of somatosensory evoked potentials. Technical note

A simple method of spinal cord monitoring that can be readily used during surgery for spinal disorders in children or adults is described. A spinal subdural recording electrode is placed rostral to the site of surgery and the peroneal nerve is stimulated in the popliteal fossa; in this way, large-amplitude polyphasic spinal somatosensory evoked potentials (SEP's) can be directly recorded. The large amplitude of the spinal SEP's recorded intrathecally facilitates spinal cord monitoring by allowing: 1) rapid acquisition of the evoked response, which provides continuous monitoring during surgery; 2) relatively easy interpretation of the signal, there being no significant ultrashort- or long-latency components to the waveform; and 3) signal acquisition in an electrical environment that would be unacceptable using standard methods of spinal and cortical SEP recording.

Congenital neural abnormalities presenting with mirror movements in a patient with Klippel-Feil syndrome. Case report

A young girl with Klippel-Feil syndrome presented with the onset of mirror movements in early childhood. Computerized tomography studies of her cervical spine and brain revealed fibrous diastematomyelia with duplication of the cervical spinal cord and an extra-axial midline posterior fossa cyst, together with the multiple cervical vertebral anomalies. Exploration of the posterior fossa lesion revealed it to be a dermoid cyst. The congenital spinal and cord abnormalities found in this case support the hypothesis that the Klippel-Feil syndrome may be associated with variable duplication of the spinal cord and that mirror movements may be related to impairment of pyramidal tract decussation.

Tuberculoma mimicking a pinealoma. Case report

Computerized tomography (CT) revealed obstructive hydrocephalus and a pineal mass in a 14-year-old girl who presented with headaches and a Parinaud's syndrome. Although there was no major evidence of extracranial tuberculosis, and cerebrospinal fluid obtained during third ventriculostomy contained no leukocytes, suboccipital transtentorial biopsy of the lesion revealed it to be a tuberculoma. Serial CT scans showed resolution of the lesion following subtotal resection and antituberculous therapy. The implications of this case with regard to difficulties in the diagnosis of cerebral tuberculoma and the management of pineal region tumors are discussed.

Experience with bucrylate (isobutyl-2-cyanoacrylate) embolization of cerebral arteriovenous malformations during surgery

The clinical experience with five patients selected for embolization of cerebral arteriovenous malformations with bucrylate (isobutyl-2-cyanoacrylate) during surgery is described. Bucrylate embolization was used to obliterate one arteriovenous malformation with a dominant nutrient arterial network, and to facilitate surgical resection in two other cases. The extent of the embolization in one of these cases was limited because of segmental perfusion of the AVM nidus by different nutrient arteries. Histological examination of this arteriovenous malformation, resected 56 days after embolization, suggested bucrylate has minimal histotoxicity. Two arteriovenous malformations were found at operation to be unsuitable for embolization because of technical problems with access and exposure of nutrient arteries, and also because of vagaries in the angiographic data before surgery. In two cases, rapid polymerization of bucrylate resulted in gluing of the injection catheters into the arterial lumen. Two patients experienced transient postoperative neurological deficits after bucrylate embolization. Because of the potential hazards of the technique, direct bucrylate embolization of cerebral arteriovenous malformations should only be considered for those lesions felt unsuitable for direct microsurgical excision, and where facilities exist for recording angiographic data before surgery.

Extrusion of peritoneal catheter through neck incision: a rare complication of ventriculoperitoneal shunting

Extrusion of the peritoneal catheter through the neck incision is reported in a man who, 14 months previously, had a ventriculoperitoneal shunt inserted for obstructive hydrocephalus. Exteriorization of CSF shunt chambers and tubing is an unusual complication of shunting, with extrusion through healed surgical incisions being rare. The authors review the causative factors, and consider aspects of surgical technique that may obviate this complication.

Spontaneous thrombosis in giant intracranial aneurysms

Twelve patients in a series of 22 with giant intracranial aneurysms demonstrated neuroradiological features of partial or total spontaneous intra-aneurysmal thrombosis. The presence of this intra-aneurysmal clot significantly altered the computed tomographic appearance of the giant aneurysm. Massive intra-aneurysmal thrombosis did not protect against subarachnoid haemorrhage and the likelihood of rupture of a clot containing giant aneurysm was not significantly different from that of a non-thrombosed giant aneurysm. Although parent artery occlusion from a thrombosed giant aneurysm, and massive aneurysmal thrombosis leading to the formation of giant serpentine aneurysm were documented, these are rare epiphenomena. The risk of embolisation from a partially thrombosed giant aneurysm, which was documented in one case, would appear to be greater than that from a non-thrombosed giant aneurysm. The findings in this series, and a review of literature, suggest that the presence of intra-aneurysmal clot in giant intracranial aneurysms has little prognostic significance and does not alter the management or outcome after treatment.

Symptomatic arachnoiditis ossificans. Report of two cases

Two cases of symptomatic arachnoiditis ossificans in middle-aged women, who had excision of ossified dorsal arachnoidal plaques, are reported. The clinicopathological features and surgical management of spinal arachnoiditis ossificans, which is a rare cause of backache and myelopathy, are discussed. The frequent association of severe contiguous arachnoidal fibrosis is considered to be a major factor accounting for the unpredictable effect of resection of stenosing and compressive ossified arachnoid.

Spontaneous thrombosis of a giant intracranial aneurysm and ipsilateral internal carotid artery. Case report

Computerized tomography revealed a thrombosed giant intracavernous carotid aneurysm in a man who presented with ophthalmoplegia and headache. Angiography confirmed complete aneurysmal thrombosis and also revealed complete occlusion of the ipsilateral internal carotid artery. Aneurysmotomy and thrombectomy produced substantial reduction in mass effect, with symptomatic improvement. The spontaneous thrombosis of giant intracranial aneurysms is discussed.

Otogenic pasteurella multocida brain abscess and glomus jugulare tumour

We report the occurrence of a Pasteurella multocida temporal lobe abscess in an elderly woman who had a history of neglected chronic purulent otitis and in whom an extensive ipsilateral glomus tumour invading the petrous bone was found. We believe this is the first report in the literature of an otogenic cerebral abscess associated with a glomus jugulare tumour and the fifth report of a Pasteurella multocida brain abscess. The synergistic pathogenesis of the otitis and the glomus tumour in the evolution of the abscess is hypothesized.

The surgical treatment of intractable childhood and adolescent epilepsy

The approach to the surgical management of intractable epilepsy of the Adelaide Children's Hospital, and a method of anaesthesia allowing intraoperative electrocorticographic recordings, are described. Using this approach, the outcome of ablative neurosurgery in a heterogenous group of sixteen childhood and adolescent epileptics is presented. This group was characterized by poorly controlled seizure disorders and interictal behavioural abnormalities. Investigations suggested that all patients had focal epileptogenic lesions. Postoperative seizure control and psychosocial adjustment were improved in 13 (81%) and 12 (75%) patients respectively. The place for, and limitations of, antiepileptogenic surgery are discussed.