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.

Results of the prophylactic surgery of lumbosacral lipomas 20 years of experience in the Paediatric Neurosurgery Department La Timone Enfants Hospital, Marseille, France

We conducted a retrospective study of children with lumbosacral lipomas treated in the Department of Pediatric Neurosurgery hospital Timone Enfants in the last 20 years. We selected patients with lipomas of the conus medullaris who underwent preventive surgery. 86 ,4 % of the patients remained asymptomatic during the follow-up. Worse results were observed in children older than one year old at surgery with transitional lipoma, with the conus medullaris was below L5 and when the resection had been partial. In view of the results, the authors recommend the preventive surgery before the first year of life under neurophysiologic monitoring in order to perform a total near-total resection with a neural plate reconstitution.

Effectiveness and handling characteristics of a three-layer polymer dura substitute: a prospective multicenter clinical study

Object

The goal of this study was to assess the effectiveness and handling characteristics of a dura substitute composed of two outer layers of expanded polytetrafluoroethylene (PTFE) and a middle layer consisting of an elastomeric fluoropolymer.

Methods

In a prospective multicenter study, the dura substitute was implanted using a standard technique in 119 patients undergoing cranial or spinal surgery requiring duraplasty. Intraoperative assessments of the dura patch consisted of testing for cerebrospinal fluid (CSF) leakage employing the Valsalva maneuver and a surgeon’s standard evaluation of the handling characteristics of the device. Postoperative assessments conducted during a mean follow-up time of 15.7 months (range 0.3–45.6 months) consisted of physical examinations, routine computed tomography (CT) or magnetic resonance (MR) imaging studies, and histological studies of any removed dura patches.

The mean age of the 119 patients was 40 years (range < 1–81 years). The dura substitute was implanted cranially in 102 patients and spinally in 17. Intraoperative assessment including the Valsalva maneuver led to application of additional sutures in 17 patients. Handling features were rated very good to excellent. Postoperative clinical evaluation resulted in 79 excellent and 18 good results. Imaging studies (MR imaging studies in 69 patients and CT studies in 34 patients) showed no adhesions in 87 patients and minimal adhesions in seven patients (the dura was not visualized in nine patients). Postoperative complications occurred in 12 patients. There were six cases of CSF leakage, three cases of extradural hematoma, one case of arachnoid fibrosis after decompression of a Chiari malformation Type I, and two cases of infection. Eight (7%) of these complications were potentially related to the dura patch.

Conclusions

In a large, multicenter clinical study of the use of an expanded-PTFE–containing dura substitute, the device was found to be easy to handle and implant. No serious dura patch–related intraoperative adverse events were observed. Postoperatively, there were no major sealing problems or long-term complications. In two cases the patch had to be removed due to fibrosis and infection. The three-layer polymer dura substitute appears to be safe and effective in minimizing CSF leakage and adhesion formation, and its use avoids any risk of prion disease transmission.

Segmental spinal cord hypoplasia and meningocele with preservation of medullary function: case report

BACKGROUND

In very rare dysraphic cases, it is not clear whether the primary abnormalities are in the neural elements, or in the bony elements.

CASE DESCRIPTION

We describe a case of segmental hypoplasia of the spinal cord, with absent nerve roots in the afflicted segments, and associated meningocele and vertebral abnormalities. We illustrate the arguments for and against the classification of this lesion either as an atypical case of myelomeningocele (MMC) or as a mild case of segmental spinal dysgenesis (SSD).

CONCLUSIONS

Possibly, in this exceptional case, the primary defect is in the neural tissue like in more usual cases of MMC and not in the spine, like in segmental spinal dysgenesis.

[Brain stem cavernomas in children. Nine case reports and literature review]

We report our experience with 9 cases of brain stem cavernoma in children aged 15 years during the period 1987-2000. All patients were admitted with lesion-related symptoms, except in one where the brain stem cavernoma was discovered on a routine MR scan. A female predominance was noted in the present study. In 2 children, brain stem cavernoma was associated with multiples lesions. All patients except two with multiple cavernomas underwent surgery. One child died 2 months after surgery from recurrent hemorrhage. The eight others are alive. Among the 8 survivors, only one has worsened. Children with brain stem cavernoma who develop persistent or progressive deficit are candidates for surgery. When surgery is indicated, total removal is mandatory to avoid the risk of recurrence and rebleeding.

[Craniopharyngioma in children: MRI study of 43 cases]

BACKGROUND AND PURPOSE

Craniopharyngiomas are intra-cranial tumors, relatively frequent in children, expanding in the pituitary stalk axis, from the third ventricle to the sphenoid body. Plain films and CT scan generally show a calcified lesion, deforming the sella turcica. MRI improves tumor description and topographic and structural analysis of the lesion. The aim of this study is to analyze the MRI aspect of craniopharyngiomas in a pediatric population and to correlate findings with surgical data.

METHODS

MR and CT studies of 43 pediatric cases of histology-proven craniopharyngiomas were reviewed retrospectively. Tumor emergence, extensions and signal on different sequences were recorded. We searched for radio-surgical correlations.

RESULTS

Craniopharyngiomas can be classified into two groups: intra-sellar tumors and third ventricle floor tumors (infundibulum and tuber cinereum). Preferential routes of extension are observed in each group correlated with consistency (cystic and/or solid). Surgical data confirmed these results.

CONCLUSIONS

MRI is crucial for the pre-therapeutic evaluation of craniopharyngiomas allowing not only a detailed description of the tumor but also guiding therapeutic decisions. This series demonstrated that craniopharyngiomas exhibit two different types of localization and behavior. Embryonic development of the tumor explains the topographical differences.

Management of brain stem abscess

The brain stem is an uncommon site of a brain abscess. Such lesions were invariably fatal before 1974, when the arrival of computed tomography and magnetic resonance imaging improved the prognosis. This new case with a good result shows the usefulness of early diagnosis, careful clinical and radiological monitoring and combined medical and surgical management. A child 2 1/2 years of age was admitted to the department of neurosurgery for diagnosis and treatment of a brain stem lesion. The clinical context and discovery of an intrabronchial foreign body, as well as neuroradiological investigations, suggested a diagnosis of brain stem abscess. Initial treatment with broad spectrum antibiotics with good cerebral penetration was associated with an increase in the size of the abscess and clinical worsening. Stereotactic aspiration of lesion was performed by a transpeduncular approach under CT guidance and general anaesthesia. Secondary thoracotomy enabled removal of an intrabronchial needle. After evacuation, in spite of failure to identify the organism, neurological deficit resolved rapidly and the lesion no longer appeared on CT. Management of a brain abscess always includes antibiotics. They must cover the organisms most often encountered in brain abscesses and have good cerebral penetration. Medical treatment seems to suffice for small abscesses. A brain stem abscess with rapid clinical signs, together with current neuroradiogical diagnostic techniques, enables early discovery of such abscesses when they are still small. Treatment of brain stem abscesses includes primary antibiotic therapy, then stereotaxic drainage when there is any diagnostic doubt, poor clinical tolerability or antibiotic resistance.

Prognostic factors in intracranial ependymomas in children

OBJECT

The occurrence of intracranial ependymomas in children is relatively infrequent, and their prognostic factors are still controversial, especially regarding histological composition.

METHODS

A retrospective study was conducted of 37 children treated during the last 20 years for intracranial ependymomas at the Hôpital de la Timone. Both univariate and multivariate statistical analyses were performed to assess the prognostic relevance of patient age and sex, extent of tumor removal, location of the tumor (supratentorial compared with infratentorial, median compared with lateral), tumor histological composition, and adjuvant therapies in affecting the 5-year progression-free survival (PFS) rate and overall survival (OS) rate. The following histopathological features, either alone or in combination, were analyzed: endothelial proliferation, necrosis, loss of differentiating structures (present compared with absent), the number of mitotic figures per 10 hpf, and cellularity (number of nuclei/5 hpf). In addition, immunohistochemical detection of Ki-67 antigen was performed and the Ki-67 labeling index (LI) evaluated in all cases. The 5-year OS and PFS rates were 45% and 25%, respectively (median follow up 34 months). Four patients died of disease without remission (median 163 days) and disease in 21 patients relapsed: 18 in situ and three both in situ and distantly. On univariate analysis total surgical resection and median infratentorial location were associated with a better outcome (p < 0.002) for both OS and PFS. Loss of differentiating structures was associated with poor prognosis (p < 0.008) and the combination of necrosis, endothelial proliferation, and mitotic index greater than 5 was also a negative predictive factor for both OS (p < 0.002) and PFS (p = 0.02). The PFS time was shorter in patients younger than 4 years of age and in patients in whom a Ki-67 LI greater than 1 was found (p = 0.03 and 0.006, respectively). Adjuvant radiotherapy and chemotherapy were not relevant to prognosis. Moreover, among the 15 patients in whom total excision was achieved, OS was better in those who did not receive adjuvant therapies. In contrast, adjuvant therapies significantly enhanced PFS time in patients in whom tumor excision was incomplete.

CONCLUSIONS

This study and analysis of the literature further highlight that total tumor removal is the treatment of choice for ependymomas in children. Postoperative measurement of residual tumor is required, especially because a subgroup of patients might be treated by surgery alone. Median infratentorial ependymomas have to be distinguished from the lateral type. Appropriate and reproducible histological parameters and Ki-67 LI are of interest as predictors of outcome.

Cytogenetic study of 33 ependymomas

Ependymomas are glial tumors. They constitute approximately 5-10% of intracranial tumors. Ependymomas are tumors which can recur. Predictive factors of outcome in ependymomas are not well-established. Karyotypic studies on ependymomas are relatively scarce, and no specific chromosomal change has been described in these neoplasms. We performed a cytogenetic study of 33 ependymomas, of which eight were recurrent tumors, to determine the type and incidence of cytogenetic changes.

Prognostic factors in pediatric spinal cord astrocytoma

BACKGROUND

Factors that could optimize the management of pediatric spinal cord astrocytoma remain unclear and controversial.

METHODS

To determine the factors that influence the prognosis of pediatric patients with spinal cord astrocytomas, a series of 73 consecutive patients at 13 French treatment centers with histologically proven spinal cord astrocytomas was retrospectively reviewed. Hospital records, operative records, and results of radiologic investigations were available in all cases. Follow-up was achieved in 94% of cases.

RESULTS

Seventy percent of the patients had low grade (1 or 2) tumors. Total or subtotal surgical resection was achieved in 43%. Thirty-six patients were irradiated following surgery. Fifty-one patients were alive at a median follow-up of 54 months. Twenty-three patients relapsed. Univariate analysis showed that good outcome was correlated with male gender, age younger than 7 years, duration of presenting symptoms longer than 2 months, the presence of spinal deformities, and low grade histology, whereas sensory loss was associated with decreased survival. Multivariate analysis using the Cox proportional hazards model confirmed that histology (relative risk [RR] = 7.69) and the interval between first symptoms and diagnosis (RR = 4.93) were significant independent prognostic factors. The extent of surgery or radiotherapy had no clear influence on survival.

CONCLUSIONS

This review sheds light on the prognoses of pediatric patients with spinal cord astrocytomas and may help to determine therapeutic strategies based on patients' clinical, radiologic, and pathologic features.

Are juvenile pilocytic astrocytomas benign tumors? A cytogenetic study in 24 cases

We performed a cytogenetic study on 24 pilocytic astrocytomas: 23 in children and 1 in a young adult. We observed 12 normal karyotypes. In 12 karyotypes with structural and/or numerical abnormalities, chromosomes 7, 8, and 11 were most frequently involved. One case recurred and presented chromosomal abnormalities (hyperdiploidy) in the first tumor and additional structural abnormalities in the second tumor. We believe that chromosomal abnormalities in pilocytic astrocytomas are frequent and indicate tumoral progression.

Intracranial meningiomas in children: review of 29 cases

BACKGROUND

Meningiomas are predominantly tumors of the fifth and sixth decades of life. Although rare in infancy and childhood, they represent an important field in pediatric neurosurgery.

METHODS

Twenty-nine children under 15 years of age with intracranial meningiomas were treated during the period 1968-1994 in the Department of Pediatric Neurosurgery in Marseille (23 cases) and in the Department of Neurosurgery of Cerrahpaşa Medical School in Istanbul (6 cases). These tumors represented 2.4% of all central nervous system (CNS) tumors in this age group.

RESULTS

There were 18 boys and 11 girls. Eighteen cases (62%) occurred between 10 and 15 years of age and two cases were infants. Twelve children (41%) had associated neurofibromatosis. Presenting symptoms were related to the tumor location. Thirty-one intracranial meningiomas were observed in these 29 children. Cerebral convexity was the most common location and 13% of the tumors had no dural attachment. Thirty-one tumors were operated on and total removal was achieved in 25 patients (86.2%). Five patients died, one during surgery. There was no mortality among the 17 children without neurofibromatosis. After a mean 6.5 year follow-up period, 13 patients (45%) are neurologically intact, 8 patients (27.5%) have a moderate disability, without evidence of tumor recurrence.

CONCLUSION

Childhood meningiomas occur predominantly in males. Absence of dural attachment is more common in children than in adults. Childhood meningiomas have a low recurrence rate. They are frequently associated with neurofibromatosis; this is the most important factor influencing outcome.

Ocular findings in children operated on for plagiocephaly and trigonocephaly

Clinical examination of patients affected by plagiocephaly or trigonocephaly reveals evident malformation of the orbits, and the ocular repercussions are pronounced when children are operated on at an advanced age. Since it is generally accepted that binocular vision is fully developed by approximately 6 months of age, a late correction of plagiocephalic or trigonocephalic skull deformities may be an obstacle to the development of normal visual function. For the present report we investigated astigmatism and strabismus in 53 children, 39 of whom were operated on for plagiocephaly and 14 for trigonocephaly. Traction on the ocular globe induced by the bony deformation caused by the craniosynostosis may explain astigmatism and strabismus.

Weaning children from tube to oral feeding

Most of the children seen by specialists in neonatalogy, neuropaediatrics or neurosurgery do not have any problems in starting with oral feeding after a period of tube feeding lasting between 15 and 20 days. Children who have been tube fed for a longer period, however, can find it very difficult or even impossible to re-establish oral feeding when they have sufficiently recovered from their underlying problem. To cope with this situation we propose a procedure based on the afferentation or re-afferentation of the oropharyngeal cavity by sensory stimulations and by re-establishment of the biological clock (circadian rhythm) by applying these stimulations during tube feeding at regular hours. In 19 children who showed difficulties oral feeding became possible a short time after such a procedure had been applied. If the principles of swallowing neurophysiology and the biological rhythm are respected, this procedure, which also involves a contribution from the family, leads to quicker oral feeding and shorter stay in hospital.

Supratentorial interhemispheric cysts associated with callosal agenesis: surgical treatment and outcome in 16 children

Cerebrospinal-fluid-filled interhemispheric cysts associated with callosal agenesis are relatively rare lesions, and have been subject to a varied and confusing terminology. From a pragmatic surgical point of view, we believe that the dorsal III ventricular cyst [35] and the giant interhemispheric cyst [23], although of different embryological origin, can be classified as one group. The most important condition that must be distinguished from interhemispheric cysts is the alobar form of holoprosencephaly. We describe the clinical symptomatology in 16 children who were surgically treated with a cysto-peritoneal shunt. The outcome, both neurologically and developmentally, was good in the large majority of cases, and compared favorably to similar cases in the older literature. It therefore seems reasonable, at the present state of knowledge and until further studies clarify the origin and natural history of these cysts, to treat them as early as possible in order to prevent gross developmental deficits.

Multiple lateral meningoceles, distinctive facies and skeletal anomalies: a new case of Lehman syndrome

We describe a 19-year-old boy who presented with facial dysmorphism, multiple lateral meningoceles, skeletal abnormalities and normal intelligence. Neurofibromatosis and Marfan syndrome were excluded. Electron microscopy of the skin showed non-specific abnormalities suggesting a connective tissue disorder. The features of this boy closely resemble those in a mother and daughter with Lehman syndrome.

Ocular findings in trigonocephaly

BACKGROUND

Trigonocephaly, caused by premature closure of the metopic suture, is a rare form of craniosynostosis. The aim of this study was to assess the visual outcome in children operated on for trigonocephaly.

METHODS

We present eight cases of children with trigonocephaly surgically corrected by the same craniofacial technique. CT with 3D reconstruction was performed in all cases. Genitori defined three types of trigonocephaly according to the severity of the deformity of the skull base only types II and III were included in this study directed at evaluation of the ocular disorder. A complete eye examination was performed on all children by the same observer, with a follow-up of 2-6 years.

RESULTS

3D-CT reconstruction of the skull base showed that the frontozygomatic region was affected by the deformation. Ocular examination showed considerable astigmatism in most children with late operation. A low degree of strabismus was observed in most children.

CONCLUSION

This study demonstrated that reconstructive surgery should be performed by the age of 6 months, given the immaturity of the visual system up to that time. Close cooperation between neurosurgeons, pediatricians and ophthalmologists is of paramount importance in order to prevent this bone deformation exerting an adverse effect on visual development. The ophthalmologist must possess a basic understanding of the various craniosynostoses.

Detection of i(17q) chromosome by fluorescent in situ hybridization (FISH) with interphase nuclei in medulloblastoma

Medulloblastomas are the most frequent primitive neurectodermal tumors in children. An isochromosome for the long arm of 17, i(17q), is found in 30% of medulloblastomas. For some authors, this abnormality is observed in cases with a shorter survival time. In our cytogenetic studies of 30 medulloblastomas, we observed i(17q) in only three cases, a monosomy 17 in two cases, a monosomy 22 in four cases, nonspecific numerical or structural abnormalities in five cases, and normal karyotypes in 12 cases. We compared the results of karyotypic analysis after culture and FISH with a chromosome 17 alpha satellite DNA probe on interphase nuclei in five cases of medulloblastoma. In one case, i(17q) was only observed in four cells in karyotypic analysis, in three cases a normal karyotype was found, and in one case karyotypic analysis was impossible. In all of these cases, i(17q) was observed in a great number of nuclei by FISH on interphase nuclei. Our study shows that the FISH on interphase nuclei permitted us to observe i(17q) in the cases where it was not or could not be completely detected by karyotypic analysis. The association of these two techniques is required to detect i(17q), an abnormality whose prognosis value in medulloblastomas is now recognized.

Brain abscess due to Gordona terrae in an immunocompromised child: case report and review of infections caused by G. terrae

A brain abscess complicated antineoplastic chemotherapy for a primary cerebral rhabdoid tumor in an immunocompromised boy. Culture of purulent exudate obtained by surgical puncture of an intracranial hematoma yielded a gram-positive microorganism initially identified as a Rhodococcus species by conventional biochemical analysis; however, the isolate was subsequently identified as Gordona terrae by ribosomal DNA analysis. To our knowledge, this is the third case of human infection caused by G. terrae and the first case of a brain abscess due to this organism. As this case demonstrates, this species may cause opportunistic invasive infection in severely immunocompromised patients. The identity of clinical isolates believed to be G. terrae should be confirmed by molecular methods until better species-specific phenotypic markers become available.

Refractive error and ocular motility in plagiocephaly

Plagiocephaly, which is caused by premature closure of one of the coronal sutures, leads to fronto-orbital asymmetry. The aim of this work was to study the repercussions of orbital deformation on the visual system. Twenty-one patients presenting with plagiocephaly at birth and operated on by the same craniofacial technique (bilateral approach with translation and advancement of the entire involved orbits) were included in the study. All of the patients were examined by clinical anthropometry with three-dimensional reconstruction and underwent complete eye examination by the same observer. Follow-up after craniofacial surgery ranged from 15 months to 4 years. In the last few years, three-dimensional reconstruction has shown that the anatomic region affected by the deformation is the frontozygomatic region and has thus made it possible to advance to another theory on the origins of ocular problems. The severe effect of orbital anomalies on the development of the visual system (binocular vision, strabismus with amblyopia, refractive errors) has been emphasized in the literature. The present study shows that the scheduling of reconstructive surgery is fundamental and must not exceed 6 months, given the immaturity of the visual system up until this time. This means that the ophthalmologist must be able to recognize the various craniostenoses in order to schedule reconstructive surgery as soon as possible. Cooperation between the neurosurgeon and the ophthalmologist is of paramount importance if the pathogenic effects of this bone deformation are to be stopped and proper visual development preserved.

The skull base in plagiocephaly

Between 1975 and 1992, 426 children with craniofacial malformations were treated in the Department of Pediatric Neurosurgery at the Hôpital des Enfants de la Timone in Marseille. Plagiocephaly was present in 71 (16.6%). The authors present a reproducible analysis of the skull base in plagiocephaly based on these 71 patients. A control group of Mediterranean children (n = 20) was used for comparison. Clinical anthropometric patterns were analyzed in all cases. Comparison with the control group showed a difference only in the nasion-lambda distance. Data obtained from clinical anthropometry were compared for the involved and the uninvolved sides. A three-dimensional reconstruction was possible in 20 cases. The statistical correlation between the basal angles (nasion-pterional, nasion-petrosal, nasion-clino-basion, and zygomatic angles) of the involved and uninvolved sides allows a new nosographic identification of this complex malformation.

[Closed spinal dysraphism]

This retrospective review included 133 patients with one or several of the following defects: diastematomyelia, neurenteric cyst, dermal sinus or cyst, meningeal malformation, sacral agenesis, tethering of the spinal cord, and lumbosacral lipoma. Physical evaluation readily identified most lumbosacral lipomas, as well as most cases of diastematomyelia since hypertrichosis over the defect was common. Some patients developed life-threatening clinical manifestations, e.g., meningitis due to a dermal sinus. On the basis of this retrospective review and a review of the literature, the clinical and therapeutic aspects of each defect are discussed.

Shunt implantation: reducing the incidence of shunt infection

Shunt infection remains the foremost problem of shunt implantation after mechanical malfunctions. Diversionary cerebrospinal fluid shunt implantation has a high complication rate, with 5% to 15% of such shunts becoming infected. Of these infections, 70% are diagnosed within 1 month after surgery and more than 90% within 6 months. Shunt infection in the vast majority of cases is therefore a complication of shunt surgery. The authors review their experience with shunt implantation during two time periods. From January, 1978, to December, 1982, 302 children with hydrocephalus underwent 606 operations. Among these children, 47 (15.56%) developed a proven shunt infection, with an incidence of infection per procedure of 7.75%. As a result of this study, a new protocol for shunt procedures involving modifications in the immediate pre-, intra-, and postoperative management of children undergoing shunt implantation was initiated. With this new protocol, 600 children underwent a total of 1197 procedures between January, 1983, and December, 1990. The incidence of shunt infection decreased dramatically, with two infections (0.33%) in 600 patients and a per-procedure rate of 0.17%. The overall annual risk of a shunt infection in the pediatric neurosurgical unit is currently 1.04%.

Cytogenetic studies in 45 pediatric brain tumors

Brain tumors are the most frequent childhood tumors. There have been few cytogenetic studies published on these tumors in children compared to the numerous studies on adult brain tumors. We examined chromosomes from 45 primary pediatric brain neoplasms including 14 medulloblastomas, 12 astrocytomas, 4 glioblastomas, 7 ependymomas, 5 craniopharyngiomas, 2 meningiomas, and 1 ganglioglioma. Chromosomal abnormalities were found in 10 medulloblastomas out of the 14 analyzed. The most frequently observed abnormalities were the total or partial loss of one chromosome 17: monosomy 17, i(17q), and a monosomy 22 in 4 cases of desmoplastic medulloblastoma. In glioblastoma, we observed the gain of chromosome 7, chromosome 3, a monosomy 10, and hyperdiploidy. The loss of chromosome X was observed in 2 cases of ependymoma as was a monosomy 22. Our observations show that from the cytogenetic point of view childhood brain tumors differ from adult brain tumors.

Cranioectodermal dysplasia with sagittal craniosynostosis (Sensenbrenner's syndrome): case report and review of the literature

We report the clinical features and neurosurgical management of a 9-month-old girl with cranioectodermal dysplasia and scaphocephaly. The technique of surgical correction is discussed together with details of the pre-operative investigations. The importance of early referral to an experienced geneticist is emphasized.

Infratentorial ependymomas of childhood. Correlation between histological features, immunohistological phenotype, silver nucleolar organizer region staining values and post-operative survival in 16 cases

We have examined pathological criteria in 16 cases of infratentorial ependymomas of childhood using a conventional histological approach, with immunohistochemistry and silver nucleolar organizer region staining (AgNORs). We have found that some of these criteria are of prognostic value. The following histological features were evaluated in each case: cellular density, cellular or nuclear pleiomorphism, mitosis, focal necrosis, endothelial proliferation and complete loss of differentiation. The expression of the following antigens was also studied: epithelial membrane antigen (EMA), human natural killer (HNK1), glial fibrillary acidic protein (GFAP) and vimentin. Only three histological criteria have been retained as indicative of bad prognosis, i.e., high mitotic index, a large amount of necrosis and complete loss of differentiation. These criteria distinguish ependymomas from anaplastic ependymomas. GFAP was expressed in all tumors while other antigens were more variable. In addition tumors expressing large amounts of GFAP were statistically associated with a better prognosis. Increased vimentin expression associated with a decrease of GFAP immunoreactivity correlated with anaplasia and short survival. EMA was not directly correlated with postoperative survival but may be considered as a further prognostic factor. Finally AgNORs values were not statistically correlated with postoperative survival.

[Meningeal hemorrhage disclosing a brain tumor in a child]

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

Skull base in trigonocephaly

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

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

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

[A cerebral abscess due to Listeria monocytogenes in a 15-month-old infant]

We report a case of brain abscess due to Listeria monocytogenes in an infant. We recall that listeriosis is infrequent in pediatric patients beyond the neonatal period, that most cases occur in immunocompromised hosts, and that clinical features are non-specific in neuromeningeal forms. Management of brain abscesses is discussed. The role of the patient's general health condition seems to have a determinant influence on prognosis.

Choroid plexus tumours in children. Review of 24 cases

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

Extradural haematoma in infants

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

[Disk calcifications in children. Apropos of 17 cases]

Seventeen cases of calcification of the intervertebral discs in childhood have been seen. Only cervical lesions gave symptoms. In several cases the lesions were multifocal (cervical and thoracic) and there was a familial history in one case. Two cases were observed for 10 and 8 years respectively. It was noted that cervical calcifications tend to disappear while thoracic ones persist but are asymptomatic. The authors postulate that this is due to differences in the physiology of the nucleus and in the biomechanics at different levels of the spine. A high frequency of associated spinal deformities was noted. For this reason, the late prognosis must be guarded.

[Pre- and postoperative endocrine function in children with craniopharyngioma ]

17 children presenting with craniopharyngioma were studied from 1970 to 1980. Presenting symptoms were usually reflecting endocrine dysfunction (13 of 17 cases), such as growth retardation, weight abnormalities, diabetes insipidus and hypothyroidism. Unfortunately, these signs were most often misinterpreted (10 of 13 cases) so that when diagnosis was made dissociated hypopituitarism was present. Further impairment of endocrine function always followed surgical excision. In most children pituitary insufficiency becomes complete and permanent. These results are similar whatever the tumor site and surgical procedure. Growth goes on and puberty occurs without treatment in a few cases but in the majority of them substitutive therapy is necessary.

Complex cerebral tumor with evidence of neuronal, glial and Schwann cell differentiation: a histologic, immunocytochemical and ultrastructural study

An unusual cerebral tumor is reported in a ten-month-old boy. The tumor was large (10 cm x 6 cm), firm and included several cysts. Light and electron microscopy showed a striking cellular pleomorphism. Typical neurosecretory ganglion cells were observed, always surrounded by Schwann cells. Amyelinic neurites, clusters of Schwann cells, fibroblasts and numerous foci of GFA positive astrocytes composed the tumor. These features were compared with the rare previous electron microscopic reports of cerebral neuronal tumor of the central nervous system. A dysembryoplastic origin from the neural plate was retained to explain the growth of such a complex tumor.

Medulloblastomas in children

The author reviews the results of treatment of medulloblastomas in children, pointing out the factors which influence the final outcome.

Macrophagic activity in intracerebral germinoma: ultrastructural study of a case

This report presents the ultrastructural study of a germinoma of the third ventricle occurring in a 13 year old boy. The electron microscopic data showed similarities linking this tumor to gonadal and mediastinal germinomas and emphasized the exceptional glycogenic storage in tumor and stroma cells. Another morphological analogy was the intense macrophagic activity that led to tumor cell phagocytosis. The authors discuss the meaning of such an immune response, which is usually not observed in cerebral tumors.