Surgical management of lobar cerebral cavernous malformations in children: a single-center experience

PURPOSE

We aimed to determine the surgical indications and postoperative outcomes among pediatric patients with lobar cerebral cavernous malformations (CCMs).

METHODS

We retrospectively reviewed pediatric patients operated on for lobar CCM between March 2010 and August 2021. Indications for surgery included (1) intracranial hemorrhage, (2) symptomatic superficially located lesion, and (3) asymptomatic CCM in non-eloquent area in case of strong parental preferences. Patients presenting with seizures were assessed using Engel Epilepsy Surgery Outcome Scale.

RESULTS

Twenty-one patients were included. The predominant symptoms were seizures (57.1%), headaches (33.3%), and focal neurological deficits (23.8%). Patients were qualified for surgery due to symptomatic intracranial hemorrhage (47.6%), drug-resistant epilepsy (28.6%), and focal neurological deficits (9.5%). Three patients (14.3%) were asymptomatic. A gross total resection of CCM with the surrounding hemosiderin rim was achieved in all patients. The mean follow-up was 52 months. No patient experienced surgery-related complications. In all individuals with a preoperative first episode of seizures or focal neurological deficits, the symptoms subsided. All six patients with drug-resistant epilepsy improved to Engel classes I (67%) and II (33%).

CONCLUSION

Surgical removal of symptomatic lobar CCMs in properly selected candidates remains a safe option. Parental preferences may be considered a sole qualifying criterion for asymptomatic lobar CCM excision.

Open fetal surgery for ventricular-amniotic valve implantation in aqueductal stenosis-dependent severe fetal hydrocephalus - a case report with 7-year follow-up

Introduction Fetal ventriculomegaly is one of the most commonly diagnosed central nervous system (CNS) pathologies of the second trimester occurring with a frequency of 0.3-0.5/1000 births. Severe fetal ventriculomegaly (SVM) may necessitate intrauterine intervention. Most such interventions have been made percutaneously with ultrasound guidance insertion of a pigtail catheter, which sadly often became obstructed or migrated. Case presentation Our case report presents the possibility of ventriculo-amniotic valve implantation (VAVI) by classic hysterotomy in isolated severe fetal hydrocephalus (IVSM) due to aqueductal stenosis. The patient was operated on similarly to OFS MOMS criteria at 24+4/7 GA, with an initial lateral ventricular dimension of 22.5 mm. A female newborn was delivered by elective cesarean section at 31+1/7 GA due to PPROM (Apgar10' 8 pts., birth weight 1600 g), required CPAP, and removal of the drainage system due to infection and narrow lateral ventricles. Evans index (EI) gradual increase and clinical symptoms of high-pressure hydrocephalus after 10 days required a ventricle-peritoneal shunt (VPS) implantation. The newborn was discharged home after 28 days with stabile hydrocephalus (EI:0.59-0.6), in good clinical condition. The 7 year follow-up was complicated by epilepsy, VPS shunt infections, delay in motor and intellectual functions (mild to moderate), and symptoms of atypical autism, the phenotype possibly related to a variant in ZEB2 gene. Conclusion Intrauterine VAVI is a one-step procedure that is effective in draining CFS. The limitations of the method remain complications due to preterm labor and infection of the drainage system.

The Price of Success-The Long-Term Outcomes of Children with Craniopharyngioma-Two Institutions' Experience

An analysis of patients below 21 years old treated due to craniopharyngioma in the years 1979-2022 was performed with the aim of evaluating the long-term outcome and treatment side-effects. The standard statistical tests were used, and 56 patients with a median age of 11 years were evaluated. Surgery was the primary treatment in 55 patients; however, in only 29 it was the only neurosurgical intervention. Eighteen children were treated with radiotherapy (RTH) in primary treatment. The most common neurosurgical side effects observed were visual and endocrine deficits and obesity, which were diagnosed in 27 (49%), 50 (91%), and 25 (52%) patients, respectively. Complications after RTH were diagnosed in 14 cases (32%). During the median follow-up of 8.4 years (range: 0.4-39.8 years), six patients died and the 5- and 10-year overall survival was 97% and 93%, respectively. Five-year progression-free survival for gross total resection, resection with adjuvant RTH, and non-radical resection alone was 83%, 68%, and 23%, respectively (p = 0.0006). Surgery combined with RTH provides comparable results to gross tumor resection in terms of oncologic outcome in craniopharyngioma patients. Adjuvant irradiation applied in primary or salvage treatment improves disease control. The rate of complications is high irrespective of improved surgical and radiotherapeutic management.

Surgical Treatment of Pediatric Incidentally Found Brain Tumors: A Single-Center Experience

There remains much debate about the correct management of incidentally found brain tumors in the pediatric population. This study aimed to evaluate the efficacy and safety of surgical treatment of incidentally found pediatric brain tumors. A retrospective analysis of pediatric patients who underwent surgical resection of incidentally found brain tumors between January 2010 and April 2016 was performed. A total of seven patients were included. The median age at the time of diagnosis was 9.7 years. The reasons for performing neuroimaging were as follows: impeded speech development (n = 2), shunt control (n = 1), paranasal sinuses control (n = 1), behavior changes (n = 1), head trauma (n = 1), and preterm birth (n = 1). Five patients underwent gross total tumor resection (71.4%), while subtotal resection was performed in two patients (28.6%). There was no surgery-related morbidity. Patients were followed up for a mean of 79 months. One patient with atypical neurocytoma experienced tumor recurrence 45 months following primary resection. All patients remained neurologically intact. The majority of pediatric incidentally found brain tumors were histologically benign. Surgery remains a safe therapeutic approach associated with favorable long-term outcomes. Considering the expected long lifetime of pediatric patients, as well as the psychological burden associated with having a brain tumor as a child, surgical resection can be considered an initial approach.

External validation of the Chicago Chiari Outcome Scale in adults with Chiari malformation type I

OBJECTIVE

The Chicago Chiari Outcome Scale (CCOS) serves as a standardized clinical outcome evaluation tool among patients with Chiari malformation type I (CM-I). While the reliability of this scale has been proven for pediatric patients, the literature lacks CCOS validation when used solely in adults. Therefore, this study aimed to determine the validity of the CCOS in an external cohort of adult patients.

METHODS

The authors retrospectively analyzed the medical records of symptomatic patients with CM-I who underwent posterior fossa decompression between 2010 and 2018 in six neurosurgical departments. Each patient was clinically assessed at the latest available follow-up. Gestalt outcome was determined as improved, unchanged, or worsened compared with the preoperative clinical state. Additionally, the CCOS score was calculated for each patient based on the detailed clinical data. To verify the ability of the CCOS to determine clinical improvement, the area under the receiver operating characteristic (AUROC) curve was evaluated. A logistic regression analysis using all four components of the CCOS (pain symptoms, nonpain symptoms, functionality, and complications) was performed to establish predictors of the improved outcome.

RESULTS

Seventy-five individuals with a mean age of 42 ± 15.32 years were included in the study. The mean follow-up duration was 52 ± 33.83 months. Considering gestalt outcome evaluation, 41 patients (54.7%) were classified as improved, 24 (32%) as unchanged, and 10 (13.3%) as worsened. All patients with a CCOS score of 14 or higher improved, while all those with a CCOS score of 8 or lower worsened. The AUROC was 0.986, suggesting almost perfect accuracy of the CCOS in delineating clinical improvement. A CCOS score of 13 showed high sensitivity (0.93) and specificity (0.97) for identifying patients with clinical improvement. Additionally, a meaningful correlation was found between higher CCOS scores in each component and better outcomes. Patient stratification by total CCOS score showed that those categorized as improved, unchanged, and worsened scored prevalently between 13 and 16 points, 10 and 12 points, and 4 and 9 points, respectively.

CONCLUSIONS

In this adult cohort, the CCOS was found to be almost perfectly accurate in reflecting postoperative clinical improvement. Moreover, all four CCOS components (pain symptoms, nonpain symptoms, functionality, and complications) significantly correlated with patient clinical outcomes.

Predictive Value of Motor Evoked Potentials in the Resection of Intradural Extramedullary Spinal Tumors in Children

This study aimed to evaluate the predictive value of motor evoked potentials (MEP) in the resection of pediatric intradural extramedullary (IDEM) tumors. Additionally, we aimed to assess the impact of MEP alerts on the extent of tumor resection. Medical records of pediatric patients who underwent resection of IDEM tumors with the assistance of MEP between March 2011 and October 2020 were reviewed. The occurrence of postoperative motor deficits was correlated with intraoperative MEP alerts. Sixteen patients were included. MEP alerts appeared in 2 patients (12.5%), being reflective of new postoperative motor deficits. Among the remaining 14 patients without any intraoperative MEP alerts, no motor decline was found. Accordingly, MEP significantly predicted postoperative motor deficits, reaching sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100% (p < 0.001). In the absence of MEP alerts, 11 out of 14 patients (78.6%) underwent GTR, while no patient with intraoperative IONM alerts underwent GTR (p = 0.025). Although MEP alerts limit the extent of tumor resection, the high sensitivity and PPV of MEP underline its importance in avoiding iatrogenic motor deficits. Concurrently, high specificity and NPV ensure safer tumor excision. Therefore, MEP can reliably support surgical decisions in pediatric patients with IDEM tumors.

External validation of the Ruptured Arteriovenous Malformation Grading Scale (RAGS) in a multicenter adult cohort

Purpose

While Ruptured Arteriovenous Malformation Grading Scale (RAGS) has recently been validated in children, the literature lacks validation on adults exclusively. Therefore, we aimed to determine the validity of RAGS on the external multicenter adult cohort and compare its accuracy with other scales.

Methods

A retrospective analysis was performed in five neurosurgical departments to extract patients who presented with the first episode of acute brain arteriovenous malformation (bAVM) rupture between 2012 and 2019. Standard logistic regression and area under the receiver operating curve (AUROC) calculations were performed to determine the value of the following scales: intracerebral hemorrhage (ICH), AVM-associated ICH (AVICH), Spetzler-Martin (SM), Supplemented SM (Supp-SM), Hunt and Hess (HH), Glasgow Coma Scale (GCS), World Federation of Neurological Surgeons (WFNS), and RAGS to predict change in categorical and dichotomized modified Rankin Scale (mRS) across three follow-up periods: within the 6 months, 6 months to 1 year, and above 1 year.

Results

Sixty-one individuals with a mean age of 43.6 years were included. The RAGS outperformed other grading scales during all follow-up time frames. It showed AUROC of 0.78, 0.74, and 0.71 at the first 6 months, between 6 and 12 months, and after 12 months of follow-up, respectively, when categorized mRS was applied, while corresponding values were 0.79, 0.76, and 0.73 for dichotomized mRS, respectively.

Conclusion

The RAGS constitutes a reliable scale predicting clinical outcomes following bAVM rupture among adults. Furthermore, the RAGS proved its generalizability across medical centers with varying treatment preferences.

Relevance of intraoperative motor evoked potentials and D-wave monitoring for the resection of intramedullary spinal cord tumors in children

The purpose of this study was to evaluate the reliability of motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), and D-wave monitoring as predictors of postoperative neurological deficits in pediatric patients undergoing resection of intramedullary spinal cord tumors (IMSCTs). Additionally, we aimed to determine whether alerts in the intraoperative neurophysiological monitoring (IONM) influenced the extent of resection (EOR). A retrospective analysis of the pediatric patients who underwent resection of IMSCT between March 2010 and April 2021 with an IONM guidance was performed. IONM alerts were recorded and correlated with patients' clinical status at discharge. Twenty three pediatric patients were included. MEP and SSEP were successfully elicited in all patients, while D-wave monitoring was feasible for 14 of them (60.9%). Significant IONM alerts occurred in 6 individuals (26.1%) with monitorable MEP and SSEP and 2 patients with monitorable D-waves (14.3%). The sensitivity, specificity, positive predictive value, and negative predictive value accounted for 100%, 81.8%, 20%, 100% for MEP, 100%, 92.3%, 50%, 100% for D-wave, and 50%, 81%, 20%, 94.44% for SSEP, respectively. Both MEP (p < 0.001) and D-wave monitoring (p < 0.001) accurately predicted postoperative motor deficits, while SSEP failed to provide significant accuracy regarding sensory deficits (p = 0.491). Gross-total tumor resection was performed in 29.4% of patients without IONM alerts and 33.3% of patients with IONM alerts, indicating that IONM alerts did not limit the EOR (p = 0.0857). MEP and D-wave monitoring can be perceived as reliable IONM modalities in pediatric IMSCTs surgery. Caution is needed with the implementation of SSEP to guide surgical decisions.

Clinical Application of Diffusion Tensor Imaging in Chiari Malformation Type I- Advances and Perspectives. A Systematic Review

BACKGROUND

Diffusion tensor imaging (DTI) application in Chiari malformation type I (CMI) is still poorly defined. This study aimed to systematically review the literature and propose perspectives toward the clinical application of DTI in CMI.

METHODS

PubMed and Embase were searched for English-language articles published until October 20, 2020. Clinical studies and case series, evaluating fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), or radial diffusivity values in patients with CMI, were included.

RESULTS

Eight articles were included. Lower FA values were found at the syrinx level, which decreased with syrinx extent and intensity of symptoms, reflecting myelopathy severity. Decreased AD and MD in the middle cerebellar peduncles in symptomatic patients with CMI might explain the presence of cerebellar signs. Increased FA in various supratentorial structures positively correlated with pain severity. Worse performance in neuropsychological tests correlated with decreased FA, increased MD, and radial diffusivity, reflecting axonal degeneration. Postoperative FA decrease in the brainstem compression area reflects successful decompression. A positive correlation was found between the extent of tonsillar ectopia and increased FA, MD, and AD values, which could act as an early indicator of acute brainstem compression.

CONCLUSIONS

DTI might provide a valuable insight into the neurobiological foundation of symptomatic CMI presentation. The severity of white matter injury evident on DTI could serve as a reliable predictor of postoperative outcomes, therefore facilitating selection of appropriate surgical candidates. Postinterventional DTI reassessment might enable differentiation between unsuccessful surgical technique and irreversible myelopathy. The extent of tonsillar ectopia reflects the severity of microstructural brainstem injury.

The features of the glymphatic system

The glymphatic system creates a network of perivascular channels. It is made of astroglia cells, whose perikaryon extensions strongly express aquaporin-4 water channels (AQP4). The pathways of the glymphatic system ensure the transport of nutrients, including glucose, lipids, amino acids, neurotransmitters, antigens, and immune cells, as well as exchange of information via afferent and efferent immune pathways. Within the glymphatic system, convective exchange of cerebrospinal fluid (CSF) and interstitial fluid (ISF) components takes place, through aquaporin-4 water channels that facilitate fluid exchange. The proper functioning of the glymphatic system allows elimination and reabsorption of solutes, metabolites, pursuit of water and ionic balance, transport of lipid signaling molecules, regulation of intracranial pressure, cerebrospinal fluid pressure, and interstitial fluid pressure. The functions of the glymphatic system are primarily affected by the influence of the sympathetic and parasympathetic innervation, sleep and wakefulness cycle, the aging process, genetic factors, and body posture. Now, the glymphatic system shows weak activity during wakefulness, while its activity increases dramatically during sleep and the state of anesthesia. Changes occurring with age begin a number of factors that impair the function of the glymphatic system pathways. Dysfunction of the glymphatic pathways causes the aggregation of incorrectly formed proteins that underlie the development of neurodegenerative diseases. Harmful protein aggregates cause prolonged inflammation. All pathologies occurring within the central nervous system (CNS), both neurodegenerative diseases and injuries, disrupt the drainage of glymphatic pathways, which are important efflux of interstitial substances and byproducts of CNS metabolism.

Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS)

PURPOSE

The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis.

METHODS

We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex.

RESULTS

Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up.

CONCLUSION

ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

Clinical features, microbiology, and management of pediatric brainstem abscess

PURPOSE

Brainstem abscess is a rare condition accounting for merely 1% of brain abscesses incidence in the pediatric population. This study aimed to present a single patient with a pontine abscess and review the literature to highlight clinical features, diagnosis, and management of brainstem abscess.

METHODS

The PubMed database was screened for English-language articles concerning pediatric brainstem abscess. We, therefore, identified 22 publications, which concisely depict 23 cases. Our study reports on the 24th pediatric patient diagnosed with that entity. All included reports were analyzed in terms of clinical presentation, diagnosis, management, and outcomes of described patients.

RESULTS

There was slight women predominance (15:9), with a mean age of occurrence 6.4 years, ranging from 7 months to 16 years. Pons was the most common location of brainstem abscess, occurring in 75% of patients. Clinically, they mostly presented with cranial nerves palsy (79.2%), hemiparesis (66.7%), and pyramidal signs (45.8%). The classic triad of symptoms, including fever, headache, and the focal neurologic deficit was present in 20.8% of patients. Positive pus cultures were obtained in 61.1%. Streptococci and Staphylococci were the most frequently identified pus microorganisms. Outcomes were satisfactory, with a 79.2% rate of general improvement.

CONCLUSIONS

Neurosurgical aspiration is a safe and beneficial therapeutic method. It should always be considered and should promptly be performed when the conservative treatment is not successful and clinical deterioration occurs. Prognosis in pediatric brainstem abscess is generally favorable. Most patients recover with minor neurologic deficits or improve completely.

Results of the surgical treatment in children with Chiari malformation type I

PURPOSE

Our study aimed to evaluate the quality of life of the patients operated due to Chiari malformation type 1 (CM-1) in the Department of Pediatric Neurosurgery, Medical University of Silesia in Katowice.

METHODS

We performed a retrospective analysis of 11 patients diagnosed with CM-1 who were treated in our center in the years 2007 to 2016. There were 6 female and 5 male individuals. Short-term evaluation of the outcome was based on comparison of the presenting symptoms and radiological images before and after the surgical treatment. Long-term follow-up was carried out using survey questionnaires based on the Chicago Chiari Outcome Scale (CCOS) devised originally by Aliaga et al. RESULTS: Patients, based on their CCOS score were divided into three groups marked as "improved," "unchanged," and "worse," depending on a range of CCOS score: 13-16, 9-12, 4-8, respectively. The outcome of patients was as follows: 6 patients (55%) were evaluated as improved, and 5 (45%) as unchanged. No patient was classified as worse after surgery. Significant negative Spearman's correlation was found between the CCOS score and patients' age at the time of surgery (R = - 0.85, p = 0.0009).

CONCLUSIONS

The decision of whether to operate pediatric patients with CM-1 should be considered very carefully. In our department, the main indication for surgery was the occurrence of clinical symptoms. Our study revealed that in the symptomatic patients, surgery improves their quality of life measured with CCOS.

How does nonsyndromic craniosynostosis affect on bone width of nasal cavity in children? - Computed tomography study

Craniosynostosis is caused by premature fusion of one or more cranial sutures, restricting skull, brain and face growth. Nonsyndromic craniosynostosis could disturb the proportions of face. Although morphometric diameters of nasal cavity in healthy children are already known, they have not been established yet in children with nonsyndromic craniosynostosis. The aim our study was to check whether diameters of bone structures of nasal cavity in children with nonsyndromic craniosynostosis measured in CT are within normal range. 249 children aged 0–36 months (96 with clinical diagnosis of nonsyndromic craniosynostosis and 153 in control group) were included into the study. The following diameters were measured on head CT scans: anterior bony width (ABW), bony choanal aperture width (BCAW), right and left posterior bony width (between bone sidewall and nasal cavity septum—RPBW and LPBW). The study group has been divided into 4 categories, depending on child’s age. The dimensions measured between bone structures of nasal cavity were statistically significantly lower in comparison to the control group. They did not depend on the sex for ABW, nor on age in groups 7–12 months and < 2 years for BCAW, RPBW and LPBW. The measured dimensions increased with age. In children with nonsyndromic craniosynostosis the diameter of pyriform aperture and bony choanal aperture were lower than in controls, what may be described as fronto-orbital anomalies. Morphometric measurements of anthropometric indicators on CT scans could be used as standards in the clinical identification of craniosynostosis type and may help in planning surgical procedures, particularly in the facial skeleton in children.

The components of shoulder and elbow movements as goals of primary reconstructive operation in obstetric brachial plexus lesions

Most of the cases of obstetric brachial plexus lesions (OBPL) show satisfactory improvement with conservative management, but in about 25% some surgical treatment is indicated. The present paper analyzes the effects of primary reconstructive surgeries in aspect of achieving delineated intraoperatively goals. Children operated before the age of 18 months with follow-up period longer than 1 year were selected. Therapeutic goals established during the operation were identified by analysis of initial clinical status and operative protocols. The elementary movement components in shoulder and elbow joints were classified by assessing range of motion, score in Active Movement Scale and modified British Medical Research Council scale of muscle strength. The effect was considered satisfactory when some antigravity movement was possible, and good when strength exceeded M3 or antigravity movement exceeded half of range of passive movement. In 13 of 19 patients most of established goals were achieved at good level, in 2 at satisfactory level. Remaining 4 patients showed improvement only in some aspects of extremity function. In 2 patients improvement in some movements was accompanied by worsening of other movements. The analysis of results separated into individual components of movements showed that goals were achieved in most of the cases, simultaneously clearly indicating which damaged structures failed to provide satisfactory function despite being addressed intraoperatively. The good results were obtained mainly by regeneration through grafts implanted after resection of neuroma in continuity, which proves that this technique is safe in spite of unavoidable temporary regression of function postoperatively.

Serum levels of vascular endothelial growth factor and basic fibroblast growth factor in children with brain tumors

BACKGROUND

Angiogenesis is the process of new vessel formation originating from the existing vascular network. It plays an important role in the growth and spread of malignancies, including brain tumors. The process of angiogenesis is characterized by increased expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), and by the release of their soluble forms into circulation.

OBJECTIVES

The aim of the study was to evaluate serum levels of VEGF and bFGF in children with malignant and benign brain tumors.

MATERIAL AND METHODS

The study group (group N) included 106 children diagnosed with brain tumors. The children in group N were classified according to tumor pathology into 3 subgroups: N1 (n = 63): patients with malignant tumors, excluding anaplastic astrocytoma (AA) and glioblastoma multiforme (GBM); N2 (n = 25): patients with benign tumors; and N3 (n = 18): patients with high grade gliomas (AA and GBM). VEGF and bFGF were determined by ELISA in blood samples before the initiation of chemotherapy. VEGF and bFGF levels were compared within the subgroups in relation to tumor grading and the extent of surgery.

RESULTS

The median VEGF in patients with brain tumors was significantly higher than in the control group. The median levels of VEGF and bFGF in subgroup N1 were significantly higher than in the control group. The differences in VEGF and bFGF concentrations between the subgroups in relation to the extent of tumor resection were not significant.

CONCLUSIONS

Significantly higher plasma VEGF levels in children with brain neoplasms may reflect enhanced angiogenesis in the tumors.

Carbohydrate-lipid profile and use of metformin with micronized fenofibrate in reducing metabolic consequences of craniopharyngioma treatment in children: single institution experience

AIM

To evaluate auxology and metabolic disturbances in children with craniopharyngioma, and to present observational results of treatment of metabolic sequels with metformin and micronized fenofibrate.

METHODS

The studied group comprised 22 children [median age at diagnosis 10.5 (0.17-16.75) years; median follow-up 5.1 years]. Assessment included height standard deviations (SDS), body mass index (BMI) SDS, concentrations of lipids, glucose and insulin (fasting or oral glucose tolerance test) and homeostatic model assessment of insulin resistance (HOMA-IR) index. Ten adolescents with hyperinsulinemia and dyslipidemia received therapy with metformin (500-1500 mg/daily) and micronized fenofibrate (160 mg/daily).

RESULTS

At diagnosis, median hSDS was -1.66 (range: -4.08; +0.1). Nine (40.9%) children were growth hormone-treated. There was gradual increase of BMI SDS, 18 (81.8%) patients being overweight at the final assessment. Dyslipidaemia was found in 19 patients (86.4%), hyperinsulinaemia in 11 patients (50%) and elevated HOMA-IR in 15 patients (68.2%). Decrease of triglycerides [median 263.5 (171-362) mg/dL vs. 154 (102-183) mg/dL] and HOMA-IR [8.64 (5.08-12.65) vs. 4.68 (0.7-7.9)] was significant in the group treated with metformin and fenofibrate for 6 months.

CONCLUSIONS

Significant auxologic changes and metabolic abnormalities were found in children treated for craniopharyngioma. The use of metformin and fenofibrate seemed to attenuate these disturbances in a short-term observation.

Infratentorial ependymomas--a study of the centre in Katowice

The aim of the study was to assess the correlation of the results of the treatment of infratentorial ependymomas with the degree of resection and histopathological diagnosis. The study was conducted on a group of 19 patients, 13 boys and 6 girls aged 3 months to 16 years, with infratentorial ependymoma treated at the Department of Paediatric Neurosurgery of the Medical University of Silesia in Katowice from January 2000 until December 2008. The most significant factor having an impact on overall survival and progression-free survival was totality of tumour resection. There has been no statistically significant influence of the histopathological type of ependymoma on the result of treatment. The tendency to report better results of treatment of non-anaplastic ependymoma seems to derive from a statistically higher frequency of total removal of tumours of this type.

Epilepsy in newborns with tuberous sclerosis complex

BACKGROUND

Epilepsy affects up to 90% of TSC patients and majority of them have seizure at the age of 3-5 months, after a period of latent epileptogenesis, but some develop epilepsy earlier.

AIMS

The aim of this work was to identify incidence, clinical characteristics, and risk factors for neonatal onset of epilepsy in a large cohort of TSC patients.

METHODS

A retrospective review of medical data of 421 TSC patients was performed. Patients who developed epilepsy within first 4 weeks of life were included in the study. Clinical and treatment data, EEG, MRI, and genetic analyses were assessed.

RESULTS

Epilepsy was present in 366 (86.9%) patients. Twenty-one (5.7%) developed epilepsy as newborns. Mean follow-up was 44.86 (6-170) months. Six patients were seizure free and 15 had drug-resistant seizures at the end of follow-up. Mental retardation was found in 81% of patients. In 11 (52.4%) patients brain MRI revealed large malformations of cerebral cortex, meeting the criteria for focal cortical dysplasia (FCD). FCD was revealed in both TSC1 and TSC2 mutation cases. Other risk factors for neonatal epilepsy included: perinatal complications and congenital SEGAs. Presence of FCD was associated with more severe epilepsy and worse neuropsychological outcome. Epilepsy surgery resulted in improvement in seizure control.

CONCLUSIONS

Neonatal onset of epilepsy in TSC is frequently associated with large malformations of cerebral cortex. Patients with FCD are at high risk of severe drug-resistant epilepsy and poor neuropsychological outcome. Early epilepsy surgery may be beneficial and should be considered in such cases.

Surgical treatment of subependymal giant cell astrocytoma in tuberous sclerosis complex patients

BACKGROUND

Subependymal giant cell astrocytoma is a brain tumor associated with tuberous sclerosis complex. There are two treatment options for subependymal giant cell astrocytomas: surgery or mammalian target of rapamycin inhibitor. The analysis of outcome of subependymal giant cell astrocytoma surgery may help characterize the patients who may benefit from pharmacotherapy.

METHODS

Sixty-four subependymal giant cell astrocytoma surgeries in 57 tuberous sclerosis complex patients with at least a 12-month follow-up were included in the study. The tumor size, age of the patients, mutation in the TSC1 or TSC2 gene, indication for the surgery, and postsurgical complications were analyzed.

RESULTS

The mean age of patients at surgery was 9.7 years. Mean follow-up after surgery was 63.7 months. Thirty-seven (57.8%) tumors were symptomatic and 27 (42.2%) were asymptomatic. Patients with TSC2 mutations developed subependymal giant cell astrocytoma at a significantly younger age than individuals with TSC1 mutations. Four patients (6.2% of all surgeries) died after surgery. Surgery-related complications were reported in 0%, 46%, 83%, 81%, and 67% of patients with tumors <2 cm, between 2 and 3 cm, between 3 and 4 cm, >4 cm, and bilateral subependymal giant cell astrocytomas, respectively, and were most common in children younger than 3 years of age. The most common complications included hemiparesis, hydrocephalus, hematoma, and cognitive decline.

CONCLUSIONS

Our study indicates that subependymal giant cell astrocytoma surgery is associated with significant risk in individuals with bilateral subependymal giant cell astrocytomas, tumors bigger than 2 cm, and in children younger than 3 years of age. Therefore, tuberous sclerosis complex patients should be thoroughly screened for subependymal giant cell astrocytoma growth, and early treatment should be considered in selected patients.

Congenital subependymal giant cell astrocytomas in patients with tuberous sclerosis complex

PURPOSE

Subependymal giant cell astrocytoma (SEGA) is a brain tumor associated with tuberous sclerosis complex (TSC). It usually grows in a second decade of life, but may develop in the first months of life. The aim of this work was to establish the incidence, clinical features, and outcome of congenital SEGA in TSC patients.

METHODS

Cohort of 452 TSC patients was reviewed to identify cases with growing or hydrocephalus producing SEGAs in the first 3 months of life. Clinical presentation, size of the tumor, growth rate, mutational analysis, treatment applied, and outcome were analyzed.

RESULTS

Ten (2.2 %) patients presented with SEGA in the first 3 months of life. All of them had documented SEGA growth and all developed hydrocephalus. In eight patients, mutational analysis was done, and in all of them, TSC2 gene mutations were identified. Mean maximum SEGA diameter at baseline was 21.8 mm. Mean SEGA growth rate observed postnatally was 2.78 mm per month and tended to be higher (5.43 mm per month) in patients with TSC2/PKD1 mutation than in other cases. Seven patients underwent SEGA surgery and surgery-related complications were observed in 57.1 % cases. One patient was successfully treated with everolimus as a primary treatment.

CONCLUSIONS

Congenital SEGA develops 2.2 % of TSC patients. Patients with TSC2 mutations, and especially with TSC2/PKD1 mutations, are more prone to develop SEGA earlier in childhood and should be screened for SEGA from birth. In young infants with SEGA, both surgery and mTOR inhibitor should be considered as a treatment option.

Radiological findings in relation to the neurodevelopmental outcome in hydrocephalic children treated with shunt insertion or endoscopic third ventriculostomy

PURPOSE

The aim of the study was to compare the radiological indicators of effectiveness for hydrocephalus treatment in children operated on under the third year of age with the use of shunt insertion (SI) and endoscopic third ventriculostomy (ETV). The effectiveness was considered in terms of postoperative neurodevelopment in correlation to pre- and postoperative radiological findings.

METHODS

The examined group consisted of 46 children operated on for hydrocephalus in the Division of Pediatric Neurosurgery in Katowice, Poland. There were 21 children treated with SI and 25 with ETV. The radiographic assessment was carried out on the basis of MRI and CT examinations with the use of a linear estimate known as frontal and occipital horn ratio (FOR). The FOR values were calculated for the entire group and in correlation to the treatment method and to the children neurodevelopment evaluated with The Denver Developmental Screening Test.

RESULTS

No differences were recognized between initial FOR value in terms of the postoperative children neurodevelopment. In the successful ETV-treated subgroup, the mean change in FOR was 0.05 and in the SI-treated subgroup, the mean change in FOR 0.13. The patients with BFOR >0.1, developed normally more often than those in whom BFOR was lower than 0.1.

CONCLUSIONS

The initial FOR value probably does not affect the postoperative developmental outcome. Long-term change in ventricles size after surgery can correlate with psychomotor development of hydrocephalic children. Presumably, there are no differences between two treatment options according to initial FOR values and to changes in FOR values.

The evaluation of function and the ultrasonographic picture of thyroid in children treated for medulloblastoma

PURPOSE

Medulloblastoma (MB) is one of the most frequent and sensitive to radiation aggressive brain tumor in children. Abnormalities of the thyroid function are common complications of head and neck irradiation for childhood cancer. The aim of this study was to assess thyroid function in children treated for medulloblastoma according to the treatment protocol phase.

PATIENTS AND METHODS

Twenty-three children with MB were enrolled to this study. All patients underwent chemotherapy and radiotherapy to the whole craniospinal axis and boost with the conformal therapy restricted to the tumor bed to a total dose of 54 Gy. Thyroid function was evaluated based on thyroid-stimulating hormone (TSH), free thyroxine (fT4) levels controlled before MB treatment, directly after irradiation and at the end of the treatment protocol. Ultrasonography has been used to detect parenchymal abnormalities.

RESULTS

All patients presented normal thyroid hormone range before chemotherapy. Hypothyroidism was found in 12 patients in the course of treatment, in 2 patients hormone deficits diagnosed directly after irradiation, in 10 patients such condition was observed at the end of the whole therapy. All of these patients needed thyroid hormone substitution. None of them presented clinical symptoms of hypothyroidism. Ultrasound-detected abnormalities have been found in 20 patients.

CONCLUSIONS

It is crucial to monitor the functions of the thyroid gland in children treated for medulloblastoma because of the high risk of hypothyroidism resulting from the treatment. The change in the echogenicity of the thyroid gland may be an early marker for a dysfunction of this organ in children treated for medulloblastoma.

Biomechanical aspects of preoperative planning of skull correction in children with craniosynostosis

Craniosynostosis is a birth defect that causes one or more sutures on a baby's head to close earlier than normal. In effect the growing brain determines an abnormal skull shape and, which is more important and more dangerous, it causes an elevated intracranial pressure. The only treatment for children with craniosynostosis is surgical cranioplasty. More extensive procedures yield excellent results, particularly in older children with moderate to severe deformity. However, in children undergoing more extensive reconstructions an essential requirement is blood transfusion. They are also put at risk of complications. In this paper, the authors propose a method of preoperative planning based on three-dimensional modelling and biomechanical investigations. We used Mimics, 3-matic and ANSYS software for the process. The proposed preoperative planning improved the preoperative knowledge of deformation, shortened the time of surgery, and subsequently reduced blood loss during the procedure.

Randomized trial of drainage, irrigation and fibrinolytic therapy for premature infants with posthemorrhagic ventricular dilatation: developmental outcome at 2 years

BACKGROUND

Preterm infants who develop posthemorrhagic ventricular dilatation (PHVD) have a high risk of cognitive and motor disability. No clinical intervention has been proven to reduce neurodevelopmental disability in such infants. We investigated whether drainage, irrigation, and fibrinolytic therapy (DRIFT), which aims to lower pressure, distortion, free iron, and cytokines, reduces death or severe disability in PHVD.

METHODS

We randomly assigned 77 preterm infants with PHVD to either DRIFT or standard treatment (ie tapping off cerebrospinal fluid to control excessive expansion). Severe disability was assessed at 2 years' corrected age and included severe sensorimotor disability and cognitive disability (<55 on the Bayley Mental Development Index).

RESULTS

Of 39 infants assigned to DRIFT, 21 (54%) died or were severely disabled versus 27 of 38 (71%) in the standard group (adjusted odds ratio 0.25 [95% confidence interval: 0.08-0.82]). Among the survivors, 11 of 35 (31%) in the DRIFT group had severe cognitive disability versus 19 of 32 (59%) in the standard group (adjusted odds ratio: 0.17 [95% confidence interval: 0.05-0.57]). Median Mental Development Index was 68 with DRIFT and <50 with standard care. Severe sensorimotor disability was not significantly reduced.

CONCLUSIONS

Despite an increase in secondary intraventricular bleeding, DRIFT reduced severe cognitive disability in survivors and overall death or severe disability.

Practical approach to childhood craniopharyngioma: a role of an endocrinologist and a general paediatrician

OBJECTIVES

The objectives of this study are to evaluate co-morbidities in patients with craniopharyngioma and to elaborate an interdisciplinary protocol of the follow-up.

PATIENTS AND METHODS

The group comprised 15 children (median age at the diagnosis, 10.1; mean follow-up period, 4 years). All patients had surgical resection of the tumour: gross total in seven, subtotal or partial removal in eight cases. Surgery was followed by radiotherapy in ten cases for tumour residue or progression. Sexual development and auxology were evaluated at diagnosis and during follow-up. Hormones were determined by chemiluminescent immunometric assays. Antidiuretic hormone dysfunction was diagnosed on the grounds of clinical symptoms, water-electrolyte balance, urine specific gravity, and serum osmolality. Metabolic control was monitored by levels of glucose, insulin, lipids, and transaminases; insulin resistance was expressed by homeostatic model assessment (HOMA) index.

RESULTS

At diagnosis, median height standard deviation score (hSDS) was -1.6 (five children being short-statured). Median change hSDS for the whole follow-up was 1.2 (four children decelerating growth). Diabetes insipidus was diagnosed in eight (within 0-1.8 years of the follow-up), hypocorticolism in eight, and hypothyroidism in 12 subjects (within 0-3.75 years for both endocrinopathies). Four patients required sex hormone replacement therapy. At diagnosis, five children were overweight; during follow-up, only four children sustained normal body mass index. Hypertransaminasaemia was found in three, dyslipidaemia in 11, and hyperinsulinaemia in seven patients (with elevated HOMA in four cases).

CONCLUSIONS

On the grounds of these observations, the management of craniopharyngioma in our institution includes repeated hormonal and metabolic assays in chosen time intervals. Early detection of co-morbidities and their management involves interdisciplinary team.

Expression of tuberin and hamartin in tuberous sclerosis complex-associated and sporadic cortical dysplasia of Taylor's balloon cell type

Focal cortical dysplasia (FCD) type IIB is a malformation of cortical development characterized by presence of balloon cells. These cells share phenotypic features of giant cells found in tuberous sclerosis complex (TSC), but the relationship between FCD type IIB and TSC is not well established. TSC is an autosomal dominant disorder caused by mutation in either of two genes: TSC1, encoding hamartin, and TSC2, encoding tuberin. Both proteins form a complex inhibiting mTOR signalling pathway and thus regulate cell size and proliferation. In this study, tuberin and hamartin expression was evaluated under a confocal microscope in six cases of Taylor's balloon cell type FCD. Three patients met the clinical criteria for TSC. In three other patients, TSC was excluded based on a panel of clinical and radiological examinations. Additionally, two cases of FCD type I and 3 samples of normal brain tissue were used as a reference group. We found loss of tuberin and hamartin expression in FCD type IIB lesions from patients with TSC. In sporadic FCD type IIB cases, only a few tuberin and hamartin positive cells were detected in the white-grey matter junction and in deeper parts of the white matter. Cortical balloon cells showed loss of both tuberin and hamartin. In contrast, the expression of tuberin and hamartin in FCD type I samples was strong, similarly to normal brain tissue. In conclusion, loss of TSC1 and TSC2 products expression in balloon cells of both cortical dysplasia type IIB in TSC-related and sporadic patients suggests that FCD type IIB may represent the focal form of TSC.

PAPILLARY PINEOCYTOMA IN CHILD: A CASE REPORT

BACKGROUND

Papillary pineocytoma is an extremely rare tumor usually with a poor outcome.

CASE REPORT

We report a case of a 10-year-old-girl with pineal gland tumor and obstructive hydrocephalus diagnosed using MRI. The child was successful treated by insertion of a ventriculoperitoneal shunt and consecutive tumor resection by supracerebellar-infratentorial approach. Histopathological examination showed a papillary structure of the pineocytoma. As such, tumors are considered to be aggressive the child was subjected to radio- and chemotherapy.

CONCLUSION

At six year follow-up after surgery, the patient is symptom-free and the MRI shows no tumor recurrence.

Randomized clinical trial of prevention of hydrocephalus after intraventricular hemorrhage in preterm infants: brain-washing versus tapping fluid

OBJECTIVE

Hydrocephalus is a serious complication of intraventricular hemorrhage in preterm infants, with adverse consequences from permanent ventriculoperitoneal shunt dependence. The development of hydrocephalus takes several weeks, but no clinical intervention has been shown to reduce shunt surgery in such infants. The aim of this study was to test a new treatment intended to prevent hydrocephalus and shunt dependence after intraventricular hemorrhage.

METHODS

We randomly assigned 70 preterm infants who had gestational ages of 24 to 34 weeks and were progressively enlarging their cerebral ventricles after intraventricular hemorrhage to either (1) drainage, irrigation, and fibrinolytic therapy to wash out blood and cytokines or (2) tapping of cerebrospinal fluid by reservoir as required to control excessive expansion and signs of pressure (standard treatment). We evaluated outcomes at 6 months of age or hospital discharge (if later).

RESULTS

Of 34 infants who were assigned to drainage, irrigation, and fibrinolytic therapy, 2 died and 13 underwent shunt surgery (dead or shunt: 44%). Of 36 infants who were assigned to standard therapy, 5 died and 14 underwent shunt surgery (dead or shunt: 50%). This difference was not significant. Twelve (35%) of 34 infants who received drainage, irrigation, and fibrinolytic therapy had secondary intraventricular hemorrhage compared with 3 (8%) of 36 in the standard group. Secondary intraventricular hemorrhage was associated with an increased risk for subsequent shunt surgery and more blood transfusions.

CONCLUSIONS

Despite its logical basis and encouraging pilot data, drainage, irrigation, and fibrinolytic therapy did not reduce shunt surgery or death when tested in a multicenter, randomized trial. Secondary intraventricular hemorrhage is a major factor that counteracts any possible therapeutic effect from washing out old blood.

Evaluation of quality of life and clinical status of children operated on for intractable epilepsy

AIM

The aim of the study was evaluation of surgical treatment of epilepsy measured by changes in quality of life (QOL) and in seizure frequency and severity.

MATERIALS AND METHODS

Examined group consists of 24 boys and 9 girls. We performed corpus callosotomy, lesionectomy, vagal nerve stimulation, temporal lobectomy and multiple subpial transections. Age at surgery ranged from 5 months to 19 years, with mean follow-up of 11.9 months. QOL was evaluated on the basis of the questionnaire created by us, in which parents were asked to assess the following variables before and after the surgical procedure: communication, socialization, daily living skills, movement abilities and behavioural problems. The seizure frequency was assessed with the Engel's scale, the modified Engel's scale and the Seizure Scoring System. Clinical state of all the patients was evaluated as well.

RESULTS

There were no patients with stable and worsening QOL status. In the whole group treated with callosotomy, the considerable improvement in QOL concerned 36.4% of cases. In more than 95% of cases, the reduction in seizures frequency is greater than 75%. In more than 43% of patients, there are no seizures after surgery.

CONCLUSIONS

Surgical treatment of intractable epilepsy is an effective method in terms of both seizure control and QOL improvement. Our results indicate the improvement in QOL of all operated patients. The improvement in QOL was accompanied by decrease in frequency and 'positive' changes in morphology of seizures. Improvement in QOL, as equivalent to seizure reduction rate, may influence further differentiation of qualification methods and surgical procedures of epilepsy.

Expression of Bcl-2 and Bax protein in normal pineal gland in children and young adult

The Bcl family contains both pro and antiapoptotic proteins participating in the regulation of neuronal cell death in several pathological conditions. However, very little is known about physiological profiles of Bcl-2/Bax expression in normal brain. In this study, we examined expression profile of Bcl-2 and Bax proteins in normal pineal gland in children. The material for analysis was obtained by biopsy of pineal parenchyma during surgery of pineal cysts. All specimens were labeled immunohistochemically and analyzed by means of confocal laser scanning microscope. We found only few Bcl-2 expressing (0.7%) and no Bax-immunopositive (0.0%) pinealocytes. Bcl-2-positive cells were mature neurons, neither young ones nor glia.

Prevention and management of painful neuroma

Painful neuroma is a common sequela of peripheral nerve injury which is usually resistant to pharmacologic treatment and requires surgical intervention. The widely accepted methods of neuroma management prevent regrowth of nerve fibers, thus precluding any functional repair. The present study reviews the currently used methods and experimental approaches to prevent and cure neuromas developing after peripheral nerve injury. The main recommendations are as follows. Special care should be taken to minimize scar formation when operating on peripheral nerves. The laser or scissors transection methods should be used to cut the nerve rather than electrocoagulation or cryoneurolysis. Direct nerve reconstruction, or, if a gap occurs, nerve grafting, should be performed immediately after nerve injury. Surgical resection of recurrent neuroma followed by implantation of the nerve into the muscle or capping the nerve stump with epineural graft seems to be the most effective method of prevention.

Difficulties in differentiation of Parry-Romberg syndrome, unilateral facial sclerodermia, and Rasmussen syndrome

INTRODUCTION

Parry-Romberg syndrome (progressive facial hemiatrophy) is a unilateral, slowly progressive atrophy affecting the skin, subcutaneous tissues, muscles, and bones. The relationship between Parry-Romberg syndrome and connective tissue disorders, especially scleroderma en coup de sabre, is still unclear. The neurological symptoms, including epilepsy, migraine, and brain lesion, on neuroimaging may be similar. Rasmussen encephalitis (RE) is connected with chronic inflammation and damage of one hemisphere. Clinically, it is manifested by epileptic partial seizures and unilateral neurological symptoms.

CASE REPORT

The authors present the case of a 10-year-old girl with features suggestive of RE, with refractory partial motor dextrolateral seizures followed by development of hemiparesis and with progressive intellectual deterioration. At the age of 2 years, some changes on the left part of the face typical of Parry-Romberg syndrome or a linear form of scleroderma were noticed.

DISCUSSION

The authors discussed the difficulties in differential diagnosis in that patient. The presented girl constitute the case from the borderline zone of the aforementioned disorders.

The cerebral form of toxocarosis in a seven-year-old patient

INTRODUCTION

Toxocarosis is a consequence of human infection by Toxocara canis larvae. There are symptomatic (visceral, ocular) and asymptomatic courses of toxocarosis. The cerebral form is very rare.

CASE REPORT

We present a seven-year-old patient who developed a cerebral form of toxocarosis. She demonstrated focal neurological symptoms (epilepsy) confirmed by neuro-imaging and histopathological examinations. A positive test for toxocarosis essentially completed the other outcomes. On the basis of the clinical picture and the conducted tests a diagnosis of a cerebral form of toxocarosis was established. Mebendazole was applied in treatment.

Malformations of cortical development in children: clinical manifestation, neuroimaging and neuropathology in selected cases

Cerebral cortical development can be divided into three steps: cellular proliferation, neuronal migration and organization. Based on known pathologic, genetic and neuroimaging features a classification for malformations of cortical development was proposed by Barkovich in 2001, and updated in 2005. Malformations of cerebral cortex development (MCCD) often demonstrate epileptic seizures and delay in psychomotor development. About 20-40% of children with epilepsy are drug-resistant and there is a large paediatric population requiring epilepsy surgery operations. In our work we performed clinical analysis of 68 children with MCCD treated in our hospital between 2000 and 2006. In our work to consider the type of MCCD we used the updated classification scheme proposed by Barkovich et al. We analyzed epilepsy, gestational and perinatal history, initial symptoms, time to establishing full diagnosis and neurodevelopmental/IQ status. In our results we found that despite similar clinical manifestation neuropathological basis could be significantly different, and vice versa: children with nearly identical neuropathological findings could have completely different neurological and radiological symptoms. Children with drug-resistant epilepsy are potential candidates for neurosurgical treatment; especially lesionectomies in such cases could be very promising in terms of epilepsy management and quality of life as well.

Aneurysmal bone cyst of the orbit

We report the case of an aneurysmal bone cyst of the left orbital roof in a 12-year-old boy who presented proptosis of the left eye and painless swelling of the left orbital rim. A 3-cm-large tumor developed in less than 3 months, with first visible signs about 2 months after a minor head injury. Radiologically, the lesion was osteolytic and multicystic. The cyst, filled with hematic fluid, was surgically removed via left frontal craniotomy and a simple curettage with high-speed bur. The patient recovered well and has been in good health throughout 14 months of follow-up.

Melatonin secretion profile after experimental pineal gland compression in rats

OBJECTIVES

Pineal gland hormone, melatonin, is a current issue of interest for accumulating data concerning its diverse physiological functions. The disturbances in melatonin secretion are observed in different pathological conditions involving pineal regions, but it is not ascertained if those disturbances present any clinical implications. The aim of this work was to examine whether pineal gland compression changes melatonin secretion.

SETTING AND DESIGN

The experiment was carried out on adult rats, divided into four equal groups: (i) control (no surgery was performed), (ii) sham-operated, (iii) with sham pineal gland compression and (iv) with pineal gland compression performed by cotton piece application.

METHODS

The profile of melatonin secretion was assessed in blood samples collected five times daily, every second day, starting from 8 to 14 day following surgery.

RESULTS

We found that surgery itself significantly increased night melatonin secretion in comparison to controls. By contrast, in pineal-gland compressed rats, melatonin secretion was lower than in control group, suggesting that the influence of pineal compression overcame that induced by operation stress.

CONCLUSIONS

In conclusion, we presume that pineal gland compression (like in case of some tumors) results in decrease of the concentration of blood melatonin, that may possibly result in decreased protective action of the indoleamine.

Pineal cysts in childhood

INTRODUCTION

Little is known about the incidence and symptomatology of pineal cysts in children. Until now, the proper management of this group of patients has not been established.

PURPOSE

The purpose of this study was to evaluate the epidemiological and clinical features of pineal cysts in children and adolescents and to try to find guidelines for their management.

METHODS AND RESULTS

We analyzed 24 patients (17 girls, mean age 9, and 7 boys, mean age 14) with pineal cysts found as the only pathology on MRI. Six patients were treated surgically (excision of the cysts via a supracerebellar-infratentorial approach) because of the progression of neurological symptoms or the enlargement of the cyst at follow-up. In this group of patients, no surgery-related complications were noted, nor was residual cyst observed on postoperative MRI. In 4 cases, histological examination revealed simple cysts, but in 2 cases pineocytomas were diagnosed. Preoperative symptoms disappeared except light headache in 2 cases and in 1 case no improvement was obtained. The remaining 18 patients had a mean follow-up of 38 months (range 24-60 months). None of the cysts diminished or collapsed. We also measured the circadian pattern of melatonin secretion as well as beta-HCG and AFP levels in serum before surgery. We found very high night levels of melatonin in both of the patients with pineocytomas, while the patients with pineal cysts showed normal or depressed melatonin secretion profile.

CONCLUSION

We concluded that though most pineal cysts were clinically benign they should be followed up for many years. If the cyst grows larger in follow-up MRI study and neurological symptoms are progressive, surgical treatment should be performed. In the authors' opinion, one of the markers discriminating benign and neoplastic lesions may be melatonin.

Endoscopic third ventriculostomy for hydrocephalus: early and late efficacy in relation to aetiology

OBJECTIVES

The aim of the study was to analyse the effectiveness and usefulness of treatment of hydrocephalus by Endoscopic Third Ventriculostomy (ETV). We sought to relate rates of failure to the cause of hydrocephalus, distinguishing between early and late outcome.

PATIENTS AND METHODS

Between September 1999 and April 2001, 30 patients underwent ETV. In 23 patients hydrocephalus was caused by an expansive mass (tumour). Three groups of patients were distinguished, according to the different aims of ETV. Thus in group T--ETV was carried out to eliminate hydrocephalus prior to the main surgery (53%), in C--ETV was the definite treatment of choice (30%), and in group P--ETV was a palliative treatment (17%). The results were assessed in the early postoperative period and in long term follow-up using clinical relief of symptoms, and radiological criteria (pre- and postoperative computed tomography and/or magnetic resonance scans).

RESULTS

In the early postoperative period ETV was rated to be effective by clinical criteria in 29 patients, and by radiological criteria in 27. According to late assessment the method was successful in 25 patients using clinical criteria, and in 21 using radiological criteria. There was no peri-operative mortality. A transient complication (wound CSF leak) occurred in two patients.

CONCLUSIONS

ETV is effective in well chosen patients in relieving symptoms of hydrocephalus. It is valuable before a definitive major operation to remove the cause of hydrocephalus, as a palliative treatment, and in itself as a method of definitive management when indications are correct.

Epidural hematomas in a child with Hutchinson-Gilford progeria syndrome

INTRODUCTION

Hutchinson-Gilford progeria syndrome (HGPS) is a rare genetic disorder. It is characterized by severe growth failure, premature aging, and very early atherosclerosis with coronary artery disease and cerebrovascular disease.

CASE REPORT

A 10-year-old boy with HGPS was admitted to our department because of progressive deterioration after a mild head injury. The CT scans revealed epidural hematoma in posterior fossa and another one in the temporal region on the left side. On admission the child was given an estimated score of 10 on the GCS. Neurological examination revealed right hemiparesis. The boy was operated on, and both hematomas were evacuated. In a few days the neurological symptoms disappeared, and he was discharged from the hospital with only residual, minimal right hemiparesis.

CONCLUSION

Intracranial pathology was certainly caused by the head trauma, but was more severe than would have been expected had the trauma been the sole cause. We suggest that progressive atherosclerosis of intracranial vessels was responsible for formation of the hematomas.

[Usefulness of melatonin in the diagnostics and therapy of pineal gland and brain neoplasms]

Melatonin or N-acetyl-5-methoxytryptamine is mainly produced by pineal gland and exhibits characteristic diurnal rhythm of synthesis and secretion with the highest levels at night and low levels during a day. For several years the knowledge of pineal gland and its hormone was rather poor. It was last years when knowledge of the role of melatonin in health and different diseases was developed. Nowadays we are aware that melatonin plays important role in diagnosis and therapy of several diseases, and may be helpful factor also in neurosurgery. Author presents the review of the present knowledge on the role of melatonin in diagnosis of pineal region pathology and treatment of brain tumors.

[Endoscopic ventriculostomy of the third ventricle in adults. Own experience]

Only few reports can be found on endoscopic third ventriculostomy (ETV) in the Polish literature, and the majority of other reports concern paediatric or mixed population. This has induced the authors to report their experience with ETV in adults, reporting the results and discussing the usefulness and effectiveness of this procedure, causes of complications and failure. ETV was carried out in 20 patients aged over 18 years in a two-year period, beginning in 1999. In 13 cases (64%) the cause was external compression of CSF system by tumour leading to hydrocephalus. In 3 cases aqueduct stenosis was producing hydrocephalus, in 3 cases arachnoid cyst, perisellar or situated in posterior part of the third ventricle, was the cause, and in one case colloidal cyst of the third ventricle. The outcome were analysed according to clinical and radiological criteria finding that the ETV was successful in 90% of cases by clinical criteria, and in 88% by radiological criteria. Only unimportant clinical complications were reported without major consequences. It is concluded that ETV is a very useful method for hydrocephalus treatment in adults, especially if caused by blockade of CSF pathways by tumour or arachnoid cysts in the vicinity of the third ventricle.

Changes in cerebral hemodynamics assessed by transcranial Doppler ultrasonography in children after head injury

INTRODUCTION

Head injury is an important factor in children's morbidity and mortality. Arterial vasospasm and probably resulting from this, delayed ischemic deficit are important sequels of head trauma with detrimental effects on outcome. These problems have already been well studied in adults, but not in children. The noninvasiveness and ease in use of transcranial Doppler ultrasound technique (TCD) make it an ideal tool for the assessment of changes in cerebral circulation not only for the purposes of diagnosis but also for follow-up.

PATIENTS AND METHODS

The authors review the present literature and analyze the usefulness of TCD as used in a group of 27 head-injured children aged 3-16 years. GCS/CCS score, CT pictures and neurological status were estimated. TCD examination was performed on the 2nd day after injury and each of the following 5 days or until normalization of flow velocities. Blood flow velocity was measured in the middle cerebral artery, the anterior cerebral artery and the extracranial portion of the internal carotid artery. The pulsatility index was also read.

RESULTS

A significant correlation was found between changes in blood flow parameters and neurological status. High blood flow velocities seemed to be caused by hyperemia rather than by vasospasm.

CONCLUSION

The results confirm that TCD is a useful method in the management of children after head injury.

[Vertebral canal abscess as a complication of congenital sacral sinus in a two year old girl]

Vertebral canal abscess is rather an uncommon disease. Since 1830, when the first report that spinal of abscess was published. Till to 2000, no more than 20 cases as a result of dermal sinus infection were reported. Dermal sinus results from an incomplete separation of the cutaneus ectoderm from the neural ectoderm between the 4 and 6 weeks of fetal development. Surgical excision of the sinus is the treatment of choice for prevention of infection. The authors describes a 2-year-old girl with that abscess secondary to dorsal dermal sinus in sacral region. The patient presented with fever, since two weeks, flaccid paraparesis mainly in the right lower extremity, urinary and bowel incontinence. The child was initially treated conservatively, and after limitation of inflammatory process the dermal sinus and dermoid cyst containing a large quantity of pus were excised. The authors reviewed the literature of spinal cord abscesses secondary to congenital dermal sinus. The diagnostic and therapeutic methods presented in the literature are discussed in comparison with our case.

Melatonin secretion in patients with pineal region tumors-preliminary report

Tumors of the pineal region, though not very common, are recently more often diagnosed due to the introduction of computer tomography and magnetic resonance examinations into neurosurgical practice. However many controversies about the treatment of them still exist. Some of them need aggressive treatment. The others are benign and asymptomatic. Thus it seems to be important to improve our diagnosis of mass lesion of the pineal region, especially before taking a decision for surgery. The purpose of this study was to find any significant changes in the circadian pattern of melatonin secretion in patients with pineal region tumors. Blood samples were collected preoperatively from 21 patients with diagnosed pineal region tumors. In 13 patients sampling was performed at 08:00, 14:00, 20:00 and 02:00 h during a 24-hour period but in 8 former ones only at 02:00 h at night. The samples were immediately centrifuged and the serum stored at -20 degrees C until analysis. The patients stayed in the darkened room from 23:00 to 05:00 h. Plasma melatonin was measured by direct and specific radioimmunoassay. The following three groups of results were found: (1) eight patients showed normal melatonin secretion profiles, (2) six cases with lack of the night maximum plasma value, and (3) seven cases with nocturnal melatonin concentration higher than in the healthy population (>100pg/ml). We observed no correlation between melatonin secretion and histological type of tumor. In conclusion, we suggest that changes of melatonin secretion could indicate the pineal region pathology. However further studies with a larger group of patients, especially with tumors originating from the pineal gland (pinealocytoma, pinealoblastoma), are necessary.

Cerebral aneurysms in childhood

OBJECTS

The aim of this work was to ascertain any clinical and anatomical factors allowing differentiation between aneurysms of childhood and those occurring in adults by comparing both groups.

METHODS

Results obtained in a total of 17 children and adolescents aged up to 18 who had been operated on for cerebral aneurysm in our department from 1989 to 1997 (3% of all patients treated for subarachnoid haemorrhage resulting from ruptured cerebral aneurysm in this period) were compared with those in the adult group operated on in our department. In contrast to the situation in adults, there was a male predominance in our population. In children we found only 1 case of middle cerebral aneurysm and 1 case of multiple aneurysms. We also found a high rate of rebleeding in the paediatric group.

CONCLUSIONS

We suggest that the very good outcome (100% very good results in patients operated on early) obtained and the high risk of rebleeding in children with cerebral aneurysm allow the recommendation of early surgery in children with ruptured cerebral aneurysms.