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.

[Benign tectal tumors: clinical and neuroradiological correlations]

Benign tectal tumours in children constitute a distinct group of brainstem gliomas, characterised by a usually benign clinical course. The aim of this paper was a retrospective analysis of 1) results of conservative treatment, 2) diagnostic value of CT and MRI and 3) correlation of the MR image with the clinical course of the disease. Our material includes 15 patients aged from 6 to 16. The treatment consisted in the implantation of a CSF-shunting device (6 children), endoscopic ventriculostomy (6 children) or ventriculostomy in a child with malfunction of a previously implanted shunt (3 cases). Follow-up periods range from 3 to 219 months (mean 46.8 mo.). A slight progression of tumour in imaging studies was noted in 3 cases, while in the remaining patients neither clinical nor radiologic progression of the disease was observed. There was no correlation between tumour size and focal contrast enhancement in MRI and the natural course of the disease. The method of choice in the diagnosis of benign tectal tumours is MRI and in the treatment of associated hydrocephalus-endoscopic third ventriculostomy. An in-depth diagnostic work-up and a more aggressive cause-oriented treatment is used only in cases of a documented clinical and radiological progression.

Risk factors of recurrence in 157 MB/PNET patients treated in one institution

To evaluate the risk factors for recurrence of MB/PNET we analyzed the medical records of 157 patients treated at the Children's Memorial Health Institute between February 1981 and February 1997. The following factors were evaluated: age at diagnosis, gender, tumor size, tumor cells in the CSF, postoperative status, extent of resection and methods of treatment. We evaluated chemotherapy (CHT) doses, interval between courses, interval between surgery (S) and first course of CHT, interval between S and radiotherapy (RTX), and breaks during RTX. We divided patients into six groups: S alone, S+CHT, S+RTX, S+CHT+ RTX, S+RTX+CHT, S+CHT+RTX+ CHT. Age at diagnosis, gender, tumor size, extent of resection, postoperative status, intervals between courses of CHT, between S and the first course of CHT, and between S and RTX, and breaks during RTX had no statistical influence on relapse occurrence. Tumor cells in CSF were routinely checked for from January 1992 onward. In this group of 75 patients, 40 had tumor cells positive at surgery (28 relapsed), while in the group of 35 patients with negative tumor cells 14 relapsed (P=0.004). Out of 26 patients treated with S+RTX alone, 13 relapsed. Among 14 patients treated with S+RTX and prolonged CHT 6 relapsed. Out of 14 patients treated with S+CHT 13 relapsed; among 49 who received S+CHT+RTX 35 relapsed; and out of 51 patients treated with S+CHT+RTX+CHT 30 relapsed. In the multivariate analysis of treatment methods chemotherapy implemented after radiotherapy had a positive, though not statistically significant, influence on outcome (P=0.06). Among those receiving CHT the mean percentage of the ideal dose administered had a statistically significant influence on relapse: in the group of relapsed patients the mean dose was 76.1%, while in the group in continuous remission it was 83.7% (P=0.0013). On the basis of our data, we conclude that the presence of tumor cells in the CSF had a significant influence on the occurrence of relapse. Administration of appropriate doses of chemotherapy is extremely important for the occurrence of relapse and the final outcome of treatment. Prolonged adjuvant chemotherapy after radiotherapy seems to lower the risk of recurrence.

[Preliminary results of the treatment of occlusive hydrocephalus in children by endoscopic techniques]

The group of 20 patients with the preliminary diagnosis of occlusive hydrocephalus were treated by neuroendoscopic technique. Ten ventriculocystocisternostomies in cases with third ventricle arachnoid cysts accompanied by hydrocephalus, 9 ventriculostomies, and 1 ventriculostomy with fenestration of posterior fossa cystic lesion were performed. It was proven that the neuroendoscopic procedures were effective in 17 cases (85%) in the 10 months mean follow-up period of the study group. With no mortality, transient surgical complications were observed in 5 cases (25%). In 3 cases, inefficacy of the method was caused by false preoperative evaluation, and inappropriate surgical technique.

Linkage studies exclude the AT-V gene(s) from the translocation breakpoints in an AT-V patient

An 8-year-old girl with severe microcephaly of prenatal onset, borderline intelligence, defects of skin pigmentation, deficiency of both humoral and cellular immunity, a normal serum alpha-fetoprotein level and hypersensitivity to ionizing irradiation is described. Spontaneous chromosomal breakage in lymphocytes together with the clinical presentation led to the diagnosis of ataxia telangiectasia variant (AT-V). In addition, the patient carried a constitutional translocation of paternal origin: 46,XX,t(3;7)(q12;q31.3) pat. In subsequent linkage and haplotype studies in 12 AT-V families with microsatellite markers from each of the translocation breakpoint regions, we could clearly exclude the localization of an AT-V gene to these regions.

[Craniopharyngioma in childhood. Significance of the extent of surgical resection and adjuvant megavoltage irradiation for event: free survival]

A series of 81 children with craniopharyngiomas is presented. All patients were operated on between 1981 and 1992. According to the applied treatment the presented group was divided into three distinct categories. 28 patients underwent what was considered by the surgeon to be total excision of their tumour, 27 bad partial excision, in the rest 26 children partial excision of the tumour was followed by local rtgtherapy. The impact on the outcome, the statistically estimated probability of event-free survival, following different type of applied treatment was the main aim of this study. The 5- and 10-year actuarial recurrence free survival rate were 78% and 52% respectively, for total removal group, versus 46% and 28% for partial removal, and 49% and 18% for partial removal followed by megavoltage irradiation. The study show a statistically significant advantage for radial surgical removal of childhood craniopharyngioma in event free survival. It is emphasized that total resection using modern diagnostic and surgical methods is the mainstay for childhood carniopharyngioma. Nearly 87% of pediatric craniopharyngiomas can be totally resected.

[The tethered spinal cord: diagnosis and surgical considerations]

The tethered spinal cord consists of complex malformations that result from disturbances in the closure of the neural tube early in embryonic development. Among patients with occult or open spinal dysraphic anomalies, late progressive neurologic deterioration commonly occurs due to a treatable cause. Most of the patients treated surgically showed improvement of their presenting complaints. The paper describes modern diagnostic methods and surgical indications. Close clinical and radiodiagnostic follow-up of this high risk patient population is indicated.

Surgical treatment of intraventricular tumors associated with tuberous sclerosis

Six children with intraventricular tumors associated with tuberous sclerosis (TS) were treated at the Children's Health Center, Department of Pediatric Neurosurgery, in the period 1987-1992. The age of the patients ranged from 7 to 15 years. TS was diagnosed according to Gomez diagnostic criteria. Computer tomography (CT) and magnetic resonance imaging showed intraventricular tumors associated with ventricular enlargement and multiple subependymal nodules commonly observed in cases of TS. All tumors were removed totally through frontal transcortical approach, with uneventful postoperative recovery. One patient, with two parallel tumors in the two frontal horns, underwent one-stage surgery with successful total removal. Histopathological examination in all cases showed subependymal giant cell astrocytoma (SGCA). The growth pattern of SGCA associated with TS, documented by sequential CT scans over several years, is described. The diagnosis and surgical treatment of the tumor are discussed, and periodic CT scanning, at least every 2 years, is recommended for patients with TS.

[Results of combined treatment of cerebellar medulloblastomas in children with chemotherapy preceding radiotherapy]

153 patients presenting with medulloblastoma between 1980-1992 were treated at the Department of Pediatric Neurosurgery, Child's Health Centre in Warszawa. This group was studied retrospectively and assessed for clinical presentation, histology, treatment regimen and survival. 44 cases treated between 1980 and 1986 underwent surgical resection, postoperative staging evaluation, and craniospinal irradiation, additionally patients assigned to "high risk" group received post-irradiation chemotherapy. Beginning 1986-86 patients with "standard risk" medulloblastoma were treated with preirradiation--"sandwich" chemotherapy consisting of either procarbazine, vincristine and CCNU or "eight drugs a day", followed by megavoltage irradiation, while "high risk" group received also postirradiation chemotherapy. The 5-year actuarial survival rate for all patients was 43%. There were no statistically significant differences in 5-year survival rate between the group treated with preirradiation chemotherapy--52%, and without--54%. The presented group was studied to identify variables of prognostic significance. The extent of disease at the time of diagnosis, as measured by M staging criteria was significantly associated with outcome. The extent of tumour resection, histological subtype of the tumour, postoperative complications, T-staging, and age did not influence the prognosis in the present study.

[Radical removal of a totally thrombosed vein of Galen aneurysm preoperatively diagnosed as a pineal neoplasm]

A case of an eight-year-old with signs of a pineal region tumor who underwent radical removal of a totally thrombosed vein of Galen aneurysm through the infratentorial supracerebellar approach. Pathophysiology of vein of Galen malformations including variety of clinical course, angiographic appearance and prognosis was described. Predisposition to spontaneous thrombosis in that type of malformations indicates necessity of taking into account such cases in the differential diagnosis of pineal region tumors.

[Results of surgical treatment of retrobulbar tumors through osteoplastic supraorbital osteotomy]

Osteoplastic supraorbital orbitotomy in operations of retrobulbar tumours minimizes the necessity of retraction of frontal lobe by change of the direction of the surgical approach. The method allows also reconstruction of the orbital roof preventing postoperative pulsating exophthalmos. The results were supported by comparison of the late control CT scans performed in patients operated by the classical transcranial approach with the examinations performed in patients operated on by the described method.

[Diagnosis and treatment of brain abscesses in children]

Fourty children were treated for brain abscess in the period 1983-1988 at the Neurosurgery Department, Children's Health Centre, Warsaw. Their age was from 4 weeks to 16 years. In 38 cases the treatment was surgical, followed by antibiotic therapy, in 2 cases only antibiotics were given. In 7 cases shunts were implanted for treatment of hydrocephalus developed in infants. Two patients died during the treatment. Problems encountered in various methods of brain abscess treatment are discussed.

[Lateral ventricle choroid plexus papillomas in infants]

Choroid plexus papillomas are rare intracranial tumours occurring most frequently in children. In the period 1983-1988 in the neurosurgery department 10 infants were treated for choroid plexus papillomas. Their age was from 4 weeks to 12 months. The diagnosis was based on the results of ultrasonography and CT. Eight patients had shunts implanted for hydrocephalus. In most cases the histological examination demonstrated benign tumours. Radical removal of the lesion was done in 90% of cases, but, despite this, remote results were satisfactory in only 40% of cases.

[Treatment of cerebral vein aneurysms in children]

Aneurysms of the vein of Galen are very rare vascular anomalies found mainly in newborns and infants. In the years 1982-1989 five children with these aneurysms were treated. Their age was from 6 weeks to 16 months, all were males. The diagnosis was based on computed tomography (initial examination) and cerebral angiography. Two cases with hydrocephalus were treated with valves. The main procedure was clipping of supplying vessels. One child died during diagnostic procedures. The results in four operated on patients are good.