Intraventricular baclofen for palliative management of acquired generalized dystonia in pediatric patients: a case series and literature review

Dystonia represents a significant source of disability in children. Generalized dystonia, which involves multiple body regions, leads to impaired mobility and motor function, resulting in substantial challenges in daily activities. Surgical treatments are used when medical treatments fail. Intrathecal baclofen (ITB) or deep brain stimulations (DBS) are the most employed surgical therapies. When these options are not feasible or ineffective, some authors have explored the use of intraventricular baclofen (IVB). In this report, we present four cases of pediatric patients with generalized dystonia who underwent treatment with IVB, resulting in notable improvements. To further explore the potential of this treatment modality, we conducted a comprehensive literature review. The findings from our study provide a comprehensive overview that can guide palliative management in similar cases.

Basal temporal lobe epilepsy: SEEG electroclinical characteristics

OBJECTIVE

Temporal lobe epilepsy is the most common type of focal drug-resistant epilepsy. Seizures with predominant involvement of basal temporal regions (BTR) are not well characterized. In this stereo electroencephalography (SEEG) study, we aimed at describing the ictal networks involving BTR and the associated clinical features.

METHODS

We studied 24 patients explored with SEEG in our center with BTR sampling. We analyzed their seizures using a quantitative method: the "epileptogenicity index". Then we reported the features of the patients with maximal epileptogenicity within BTR, especially ictal network involved, ictal semiology and post-surgical outcome.

RESULTS

We found that rhinal cortex, parahippocampal cortex and posterior fusiform gyrus were the most epileptogenic structures within the BTR (mean EI: 0.57, 0.55, 0.54 respectively). Three main groups of epileptogenic zone organization were found: anterior (23% of total seizures) posterior (30%) and global (47%, both anterior and posterior). Contralateral spread was found in 35% of left seizures and 20% of right seizures. Naming deficit was more prevalent in left BTR (71% vs 29% in right seizures; p = 0.01) whereas automatic speech production was preferentially represented in right seizures (11% vs 54%; p = 0.001). Surgery was proposed for 11 patients (45.8%), leading to seizure freedom in 72% (Engel Class I). One patient presented post-operative permanent functional deficit.

CONCLUSION

Basal-temporal lobe epilepsy seems to be a specific entity among the temporal epilepsy spectrum with specific clinical characteristics. Resective surgery can be proposed with good outcomes in a significant proportion of patients and is safe provided that adequate language assessment has been preoperatively made.

Judicial handling of cases of non-accidental head trauma in infants: Review and analysis of expert assessments

INTRODUCTION

Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis. The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI.

METHOD

A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis.

RESULTS

In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases.

CONCLUSION

Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.

A child dural-based occipital cavernoma with an accessory venous sinus

BACKGROUND

The diagnosis of extra-axial cavernoma and surgical decision-making can be difficult on children.

REPORTED CASE

In this report we present the case of a 33-month-old child for whom the work up done for asthenia, anorexia and psychomotor regression reveals a well-defined occipital extra-axial lesion. A follow up MRI was performed two months later, revealing an increase in the size of the lesion associated with hemorrhagic changes. The surgical decision is performed after an arteriography; it allows the total removal of the lesion contained in a duplication of the dura mater, by placing a vascular clip on an accessory venous sinus draining the lesion, respecting the integrity of the lateral sinus. Histology confirms a cavernoma. No complication resulted from the surgical procedure. This atypical case of pediatric dural cavernoma associated with a well-defined accessory venous sinus in arteriography is to our knowledge the first description in the literature.

CONCLUSION

Extra-axial cavernomas have a misleading presentation. The management of these lesions is of twofold interests: to avoid a repercussion on the development of these children, and to obtain histological confirmation.

Upward vectors for osteogenic distraction treatment in secondary chronic intracranial hypertension in children undergoing scaphocephaly surgery: 2 cases reported

The occurrence of secondary synostosis of coronal sutures at distance from H-craniectomy surgery for scaphocephaly concerns about 10% of children. Intracranial hypertension in these children remains exceptional but generally requires a surgical reoperation. Two children aged 3 and 5- months- old had been operated for scaphocephaly by H-craniectomy in two different hospital centers. Their clinical follow-up described a partial persistence of dolichocephalic deformity and an impression of parietal stenosis. During their growth, chronic headaches appeared with a complaint expressed at the ages of 4 and 5 years. In both cases, ophthalmic examination revealed significant bilateral papillary edema without loss of visual acuity. The imaging assessment (CT-scan and MRI) showed the absence of Chiari malformation and venous abnormality. For both, there was a compression image of the parietal lobes in relation to the persistence of a temporoparietal synostosis. An osteogenic parietal distraction permitted a volumetric brain expansion consecutive to the skull and meninges remodeling in only 6 months, associated with a leap forward acquisition, a normalization of the ophthalmic examination, and a complete loss of headaches. In conclusion, this new approach could be used in the case of chronic intracranial hypertension consecutive to a secondary parietal synostosis after a scaphocephaly surgery.

Craniosynostosis and oculomotor disorders

Simple, complex or syndromic craniosynostosis may be responsible for ocular and especially oculomotor pathologies. Among simple craniosynostosis, anterior plagiocephaly is the most frequently associated with oculomotor disorders. Oculomotor disorders encountered in craniosynostosis are specific to this pathology. They may be related to orbital deformities or oculomotor muscle malformations. Early craniofacial surgery reduces the onset and severity of these oculomotor disorders which is very important for ophtalmological patient care. Indeed, these oculomotor disorders are difficult to treat for the ophthalmologist with most of the time several surgeries needed, and lead to amblyopia if neglected.

Ibuprofen as risk-factor for complications of acute anterior sinusitis in children

IMPORTANCE

Non-steroidal anti-inflammatory drugs (NSAIDs) are known to inhibit chemotaxis, oxidative burst and phagocytosis, bacterial killing in granulocytes as well as inhibiting neutrophil aggregation or degranulation, thereby interfering with the function of lymphocytes. On the other hand, ibuprofen is widely prescribed in pediatrics for its powerful analgesic and antipyretic effects. To our knowledge, no previous publication outlines the relationship between Ibuprofen therapy and an increased risk of intracranial and/or orbital complications of acute fronto-ethmoidal sinusitis in childhood.

OBJECTIVE

To look for a relationship between ibuprofen and occurrence of intra-cranial and/or orbital complications of acute fronto-ethmoidal sinusitis in pediatrics.

SETTING AND METHODS

The medical charts of patients younger than 18 years admitted into the E.N.T. departments of 4 academic care centers during 2 consecutive years for fronto ethmoidal sinusitis were reviewed retrospectively. The history of ibuprofen intake, the occurrence of complication (orbital or intracranial) as well as the usual demographic data were noted. A statistical analysis was performed in order to ascertain whether a relationship between taking NSAIDs and the onset of an intracranial and/or orbital complication exists.

RESULTS

Intake of ibuprofen appeared to be a risk-factor of intracranial complications or associated orbital and intracranial complications of acute fronto-ethmoidal sinusitis in children. Neither gender nor age nor initial pain intensity were statistically related to the onset of complications.

CONCLUSION AND RELEVANCE

This retrospective multicenter cohort study appears to suggest that ibuprofen increases the risk of orbital and/or intracranial complications of acute fronto-ethmoidal sinusitis in childhood. Therefore, we recommend not prescribing ibuprofen if one suspects an acute sinusitis in a child or adolescent.

Multiple neurosurgical treatments for different members of the same family with Currarino syndrome

INTRODUCTION

Currarino's syndrome (CS) is an autosomal dominant disorder of embryonic development causing a rare malformating syndrome characterized by a triad of an anorectal malformations, presacral mass (most commonly an anterior sacral meningocele) and sacral bony defects. Mutations of the HLXB9 gene have been identified in most CS cases, but a precise genotype-phenotype correlation has not been described so far. Family screening is obligatory. The diagnosis is usually made during childhood and rarely in adulthood. In this context, imaging, and especially MRI plays a major role in the diagnosis of this syndrome. Surgical management is provided by pediatric surgeons or neurosurgeons.

FAMILIAL CASE REPORT

Here, we present a family case report with CS requiring different neurosurgical management. The son, a 3-year-old boy, developed a tethered spinal cord syndrome associated to a lipoma of the filum terminale, a sacro-coccygeal teratoma and an anal adhesion. A combined surgical approach permitted a good evolution on the urinary and digestive functions despite a persistent fecal incontinence. The 2-year-old daughter presented with a cyst of the thyreoglossal tract infected and fistulized to the skin. She was also followed for a very small lipoma of the filum terminale that required a neurosurgical approach. The father, 44-year-old, manifested functional digestive and urinary disorders caused by a giant anterior sacral meningocele. The ligation of the neck of the cyst and aspiration of the liquid inside in full through a posterior partial approach permit a complete collapse of the cyst with an instantly satisfactory clinical outcome.

CONCLUSION

In these cases, cooperation between pediatric surgeons and neurosurgeons was crucial. The follow-up of these patients should be done in a spina bifida clinic. A geneticist evaluation must be offered to the patient in the case of a CS as well as a clinical evaluation of the relatives (parents, siblings).

Selective suppression of excessive GluN2C expression rescues early epilepsy in a tuberous sclerosis murine model

Tuberous sclerosis complex (TSC), caused by dominant mutations in either TSC1 or TSC2 tumour suppressor genes is characterized by the presence of brain malformations, the cortical tubers that are thought to contribute to the generation of pharmacoresistant epilepsy. Here we report that tuberless heterozygote Tsc1^+/− mice show functional upregulation of cortical GluN2C-containing N-methyl-D-aspartate receptors (NMDARs) in an mTOR-dependent manner and exhibit recurrent, unprovoked seizures during early postnatal life (<P19). Seizures are generated intracortically in the granular layer of the neocortex. Slow kinetics of aberrant GluN2C-mediated currents in spiny stellate cells promotes excessive temporal integration of persistent NMDAR-mediated recurrent excitation and seizure generation. Accordingly, specific GluN2C/D antagonists block seizures in Tsc1^+/− mice in vivo and in vitro. Likewise, GluN2C expression is upregulated in TSC human surgical resections, and a GluN2C/D antagonist reduces paroxysmal hyperexcitability. Thus, GluN2C receptor constitutes a promising molecular target to treat epilepsy in TSC patients.

Tuberous sclerosis complex (TSC) is a rare genetic condition characterized by epileptic seizures that start in infancy. Here, the authors show that these seizures are modulated by GluN2C-containing NMDA receptors in the cortex of a mouse model of TSC, and that suppressing their activity attenuates seizures.

[Eyelid approach and pediatric orbital tumors: indications and surgical technique. About three children]

Interdisciplinary collaboration can offer unusual approaches for the treatment of orbital pathologies. The authors report their experience with the eyelid incision in treating three children with epidural orbitary hematoma, dermoid cyst of the upper outer quadrant and a dermoid cyst of the internal inferior quadrant. For all the children, removal was complete and cosmetic results satisfying. The authors discuss the indications and complications of this surgical approach.

KIAA0510, the 3'-untranslated region of the tenascin-R gene, and tenascin-R are overexpressed in pilocytic astrocytomas

AIMS

Studying the molecules and signalling pathways regulating glioma invasiveness is a major challenge because these processes determine malignancy, progression, relapse and prognosis. We took advantage of our previous study focused on genes that were critical in tumour invasion to further study here an unknown sequence, referred to as KIAA0510, the chromosomal location of which was 1q25, described as a 5596-bp long mRNA and that we found to be significantly overexpressed in pilocytic astrocytomas compared with glioblastomas.

METHODS AND RESULTS

Using in silico analysis as well as Polymerase chain reaction techniques, we decipher the full genomic characterization of the KIAA0510 sequence and demonstrate that KIAA0510 constitutes the 3'-untranslated region of tenascin-R gene. We have clearly confirmed the overexpression of tenascin-R in pilocytic astrocytomas vs. glioblastomas at mRNA and protein levels. We also analysed a large series of various brain tumours and found that in the group of astrocytic tumours, tenascin-R expression decreased with malignancy, whereas oligodendrogliomas sometimes retained a high level of tenascin-R even in high-grade tumours. Gangliogliomas strongly expressed tenascin-R too. In contrast, ependymomas and meningiomas were negative. In normal brain, tenascin-R was exclusively expressed by normal oligodendrocytes and subsets of neurones during post-natal development and in adulthood, where it could differentially affect cellular adhesiveness and/or differentiation.

CONCLUSION

KIAA0510, the 3'-untranslated region of the tenascin-R gene, and tenascin-R are overexpressed in pilocytic astrocytomas. Gangliogliomas shared with pilocytic astrocytomas strong tenascin-R expression. Whether tenascin-R overexpression negatively influences brain invasion remains to be determined.

Peri-insular hemispherotomy in children: a single institution experience

The objective of this paper is to evaluate our experience in performing peri-insular hemispherotomy in refractory epileptic children. First, we address the history of hemispheric surgeries for epilepsy and then we compare our results to the medical literature in term of seizure control and complications. Between 1993 and 2007, 14 children who suffered from refractory hemispheric epilepsy underwent a peri-insular hemispherotomy. All children's charts were reviewed in a retrospective manner. Age at onset of epilepsy, imaging studies, cause of refractory epilepsy, electroencephalography findings, type of epileptic seizure, number of antiepileptic drugs (AED), preoperative neuropsychological evaluation and surgical outcome with regard to the children's seizure activity were analyzed. Nine boys and 5 girls were enrolled in this study. The mean age at onset of epilepsy was 16 months (range birth-5 years). All the children presented complex partiel seizures. Seizure frequency varied from 5 to 100 a day. The average delay prior to the hemispherotomy was 83 months (range 12-226 months). Mean age at the time of the surgery was 8.4 years (range 1.7-18 years). We performed 9 peri-insular hemispherotomies on the right side and 5 on the left. There were no reported surgical complications in this series. 10 children are seizure free (72%). Peri-insular hemispherotomy must be considered as a safe and very efficient therapeutic approach for children suffering from hemispheric refractory epilepsy. Peri-insular hemispherotomies are procedures where pathology and surgical technique interact narrowly. Acquired pathologies had better results than developmental ones.

Vagus nerve stimulation in pediatric epileptic syndromes

Vagal nerve stimulation (VNS) has shown promising results in various cohorts of non-surgical refractory epilepsy in adults and children. However studies report a significant delay between implantation and clinical response. We describe a cohort of 28 children and adolescents prospectively followed, classified by epileptic syndromes and treated with VNS using a 6-week rapid ramping protocol between January 2000 and March 2005. Our cohort showed favorable outcome within 6 months which was sustained at 24 months: 68% (19/28) showing >or=50% reduction in seizure frequency, including 14% (4/28) who became seizure-free. VNS was particularly efficacious in children with cryptogenic generalized and partial epilepsies. Although adverse events occurred in 68% (19/28) of patients, most were transient. In conclusion, rapid ramping is associated with an early and lasting response in most children but with a slightly higher side-effect rate.

Atypical teratoid/rhabdoid tumour: 7-year event-free survival with gross total resection and radiotherapy in a 7-year-old boy

CASE STUDY

We report the case of a 7-year-old boy who presented in 1998 a tumour of the left frontal lobe. Initially diagnosed as anaplastic ependymoma, the boy was treated by gross total resection followed by radiotherapy at the operated site. In July 2005, an orbital tumour was discovered and resected. The tumour was composed of sheets of rhabdoid cells which diffusely expressed vimentin and focally epithelial membrane antigen (EMA) and alpha-smooth actin by immunohistochemistry. The first tumour was re-examined. Small foci of rhabdoid cells were found. Immunohistochemistry anti-INI1 performed on both tumours was negative. Molecular techniques performed on frozen specimen of the orbital tumour confirmed the diagnosis of atypical teratoid/rhabdoid tumour (ATRT).

DISCUSSION

We discuss the pathological criteria for diagnosis of ATRT and the usefulness of early radiotherapy in the light of the recent literature.

[Trans-umbilical access and ventriculoperitoneal shunt in adults: preliminary results]

In spite of the development of endoscopic surgery in hydrocephalus, ventriculoperitoneal shunt remains indicated in many cases particularly for non obstructive hydrocephalus. The peritoneal cavity is always an excellent receptacle for the LCS at the price of an unaesthetic abdominal scar, which may pose a problem, especially for the young adult. The trans-umbilical approach allows us to avoid the unsightly scar. Thus, between May 2004 and September 2006, a ventriculoperitoneal shunt was fashioned in 14 patients using a trans-umbilical access. Average age was 52 years and average post-intervention follow-up was 17 months. No patient developed infection, in particular in the umbilical area. One patient had to undergo a second operation for ventricular repositioning using the same peritoneal drain that could be repositioned via the trans-umbilical access with no particular problem. In one particular case, a full change of the shunt was necessary because of a sore on the shunt chamber, the material was reinstalled via the conventional umbilical access without any particular difficulty. This is the first preliminary study which confirms the feasibility of the trans-umbilical method for adults with no increase in the infectious risk, and with a very satisfactory aesthetic result in children.

Cavernomes du système nerveux central chez l'enfant

Cavernomas represent 1.7 to 18% of all vascular malformations in children and 25% are observed in children under 18 years of age. Cases observed in neonates and infants have been published, but the mean age varies from 9.1 to 10.2 years. There is no predominance between boys and girls.

CLINICAL PRESENTATION

In children, hemorrhage is a common manifestation with an incidence varying from 27.3 to 78% versus 8 to 37% in adult patients. Isolated headaches occur in 2.8% of patients and elevated ICP is observed in 20.1%. Epilepsy is reported in 16 to 60% of children, depending on the series. Neurological deficits are observed in 22.7% of patients and are more severe for deep-seated and brainstem cavernoma. About 14.2% of the cases are discovered fortuitously in asymptomatic patients. Spinal cord deficits are observed in 5% of the cases.

LOCATION

Using data in the literature plus our personal series of 57 cases, 79.4% of lesions are in the supratentorial compartment and 20.6% in the posterior fossa, the majority located in the brainstem, most of them in the pons. Spinal cord cavernomas represent 5% and multiples cavernomas (12.6%) of the reviewed cases.

MANAGEMENT

Appropriate management of cavernomas has long been a subject of much debate. Today, a consensus has been reached to favor medical management of asymptomatic and non hemorrhagic lesions and surgical management of symptomatic and/or hemorrhagic cavernomas whatever the localization. Progress in neuroimaging, surgical mapping, intraoperative monitoring and microsurgical techniques has greatly contributed to improved approach to those lesions.

RESULTS

Results obtained in 217 cases were reviewed. Near 70% of the children are neurologically intact, 19.3% are improved or stable, 2.7% worsened and 1.13% died. Results for epilepsy are very encouraging, surgery is efficient in almost all the children except for temporal lobe cavernomas where invasive presurgical evaluation is recommended. Deep-seated and brainstem cavernomas can safely be removed in most of the cases. Only two children died from recurrent hemorrhage due to residual lesions.

Les oligodendrogliomes supratentoriels de l’enfant

BACKGROUND AND PURPOSE

The goal of this study was to analyze the main aspects of oligodendrogliomas observed in children.

METHOD

The records of 35 children aged 15 years or younger (23 from Marseilles and 12 from Lyons) were reviewed. Clinical signs and symptoms, imaging findings (CT scan and pre- and post-operative MRI), extent of surgical resection, histology according to the WHO and Ste-Anne grading and survival were analysed. Considering all these factors, a statistical analyzis was undertaken in order to identify prognostic factors.

DISCUSSION AND CONCLUSION

Oligodendrogliomas are rare tumors in children. The most important differential diagnosis to discuss is dysembryoplastic neuroepithelial tumor. Our study allowed us to distinguish several subgroups of patients with a different prognosis: thalamic tumors with a dismal prognosis versus hemispheric tumors. A group of cortical tumors we called "DNT-like" (hemispheric cortical tumor, isolated epilepsy, without neurological deficit and reased ICP, without edema and mass effect on MRI) with an excellent prognosis like the group with epilepsy. Histological grading (grade A/grade B and grade II/grade III) is also a prognostic factor.

Acquired aqueductal stenosis in preterm infants: an indication for neuroendoscopic third ventriculostomy

OBJECT

The object of this study is to demonstrate the delayed occurrence of aqueductal stenosis in preterm infants who have suffered from intraventricular hemorrhage (IVH) and to try to explain the mechanisms of this stenosis.

METHOD

From January 1996 to June 2002, 1,046 premature infants were admitted to our institution. Thirty-six neonates suffered from grade 3 or 4 intraventricular hemorrhage (Papile grading), of whom 16 died. Twenty patients survived and a ventriculoperitoneal shunt was inserted in 7 infants. Four patients underwent a neuroendoscopic third ventriculostomy. Follow-up was carried out, twice a month during the first 2 months and subsequently twice a year.

CONCLUSION

In 2 children NTV was an effective treatment for hydrocephalus with an average follow-up of 29 months. The specific pattern concerning these patients is the long delay before obstructive hydrocephalus and the visualization of de novo obstruction with MRI. The biological explanation must be investigated.

[Unsuccessful surgery of Cushing's disease. Role and efficacy of fractionated stereotactic radiotherapy]

BACKGROUND AND PURPOSE

To optimize and reduce the toxicity of pituitary adenoma irradiation, we evaluated the feasibility and effectiveness of fractionated stereotactic radiotherapy (FSR) in 51 patients with functional adenoma; 12 of them had Cushing's disease.

PATIENTS AND METHODS

Eleven females and one male, median age: 49 years, 8 of them relapsed and 4 had persistent hormonal secretion after surgery. The delivered dose was 50 grays (Gy) (5 x 1.8 Gy/week) using 5 convergent micro-beams scanning in arc therapy mode. The median planned target volume (PTV) receiving 90 to 100% of the total dose was 2,1 cm(3). We used relocatable non-invasive stereotactic device Brain Lab, and adapted Linac for stereotactic radiotherapy.

RESULTS

Nine out of twelve patients (75%) presented with complete remission after a median time of 29 months, 3/12 patients with partial remission. Actuarial probability to have hormonal persistent secretion was 88% at on year, 44% from 3 to 5 years, 22% at 7 years, and 11% to 0% after 7 years. The 12-corticotroph adenomas were significantly (p=0.007) more radiosensitive than 39 non-corticotroph adenomas. Toxicity was significantly lower for corticotrope adenoma, with no radio-induced pituitary deficiency and no neurological or optic injury.

CONCLUSIONS

Combined surgery and FSR appears to be safe and effective for treatment of pituitary adenomas. However, long-term follow-up is required to determine the impact in terms of tumor response and hormone deficiency. The focused treated volume obtained by FSR seems more suitable for these benign tumours than standard radiotherapy. In addition to this conformal approach, the use of standard fractionation reduced the risk of severe damage to the optic chiasma, which is sometimes observed after radiosurgery and is inherent in single fraction radiotherapy.