common neurosurgical disorders in children
TRANSCRIPT
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Common Neurosurgical Problems in Children
Dhaval ShuklaAdditional Professor of Neurosurgery
NIMHANS, Bangalore
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• Hydrocephalus
• Congenital Malformations
• Brain Tumors
• Head injury
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Brain Tumors• 20-30% of cancers in children• 2nd most common neoplasm• Most occur before age 10 years• Male/Female = 1.3/1.0
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Symptoms in Small ChildrenMacrocephaly 40%Vomiting 30%Irritability 25%Lethargy 21%Abnormal Gait/ Coordination 18%Weight Loss 15%Raised ICP 10%Seizures 10%Focal Neurological Deficits 10%Abnormal Eye Movement 5%Developmental Delay 5%
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Histological Types
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Diagnosis
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Treatment
Tumor Type Surgery XRT ChemoMedulloblastoma +++ CrSp +++Low grade astro +++ focal ---- cerebellar +++ ???? ----
optic glioma NO ???? ????High grade astro/GBM +++ +++ ?Brain stem glioma (exophytic) focal ?Ependymoma +++ focal ----Germ cell tumor ? bx +++ +++
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Treatment - Surgery
• In general, needed for diagnosisExceptions: Germ cell, Brainstem
• Ideal is gross total resectionBalance prognosis vs. morbidity
• Debulking, shunts, reservoirs- For symptom/ICP reduction, therapy
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SurvivalType of Tumor 5-Year Survival
Pilocytic astrocytoma About 95%
Fibrillary (diffuse) astrocytoma About 85%
Anaplastic astrocytoma About 30%
Glioblastoma About 20%
Oligodendroglioma About 95%
Ependymoma/anaplastic ependymoma About 75%
PNETs (includes medulloblastoma and pineoblastoma) About 60%
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Brain Tumors in < 3 year olds
• 60-70% supratentorial• XRT has significant neuro-cognitive effects• Goal of therapies: – Delay XRT to at least 3 yrs old with chemotherapy
most relapse prior to XRT• Current Recommendation– Short course (16 wks) chemotherapy– 2nd look surgery– Focal (conformal) XRT– Maintenance chemotherapy
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Large, Small, and Abnormal Head
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• Macrocephaly (Head circumference > 97th percentile) – Hydrocephalus• Enlargement of the ventricles
– Macrocrania • Increased skull thickness
– Megalencephaly • Enlargement of the brain
• Microcephaly (Head circumference < 3rd percentile)– Craniosynostosis• Abnormal shape of the skull
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Hydrocephalus
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Hydrocephalus – Treatment Options
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Shunt Malfunction
• 30% to 40% of shunts fail in the first year• 15% fail in the second year• After 2 years failure rate 1% to 7% per year • Obstruction is responsible for the majority of
failures– 60% proximal catheter– 30% at the valve itself– 10%distal tubing
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Antibiotic-impregnated VP Shunt
• 0.15% clindamycin and 0.054% rifampicin• 11 observational studies showed a statistically
significant difference favouring the antibiotic-impregnated VPS (RR: 0.37, CI: 0.23, 0.60; P <0.0001)
• One RCT did not show a significant difference between two groups in the risk of shunt infection (RR: 0.38, CI: 0.11, 1.30; P = 0.12)
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Silver-impregnated VP Shunt
• Efficacy of silver-impregnated catheters at preventing VPS infections is not yet proven
• RCT of EVDs in children and adults, silver-impregnated EVDs have been shown to reduce infection from 21.4% (30/140) to 12.3% (17/138) (P = 0.042)
• Two further observational studies comparing standard to silver-impregnated EVDs have also shown a reduction in infection rates
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• Neuroendoscopy in Infants and the International Infant Hydrocephalus Study
• BASICS trial: British antibiotic and silver-impregnated catheters for VP shunts
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Hydrocephalus – Prognostic Factors
• Etiology – Worse with meningoceles• Motor and sensory deficits• Level of meningocele• Seizures• Degree of ventricular dilatation • Age at surgery• Shunt function and complications
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Hydrocephalus - Outcome
• Developmental disorders • Reduced motor function• Lower IQ• Decreased visual function• Risk for developing epilepsy
– Children with epileptic seizures have the worst outcomes and more likely to have lower IQ
• About 60% of children with hydrocephalus are able to attend school (although many have difficulties)
• About 40% of children will lead relatively normal lives
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Craniostenosis
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Craniostenosis
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Craniostenosis
• Surgery– Cosmesis– Brain Development
• Extent of surgery– Conservative surgery in small children– Extensive cranial vault remodeling after 6 months
• Complications– Blood loss– Hypothermia
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Head Injury
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Traumatic Brain Injury
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Mild Head Injury
• Controversy regarding policy for hospital admission and evaluation with CT scan
• CT scan is desirable– For detection of significant intracranial lesion– Children with brain lesions have greater cognitive impairment– Children with normal CT scan can be discharged
• CT scan is not advisable for all children because of a remote risk of cancer– Clinical benefits of CT scan should outweigh the small absolute
risks– Justification of any CT scan is important
A decreasing order of probability of intracranial injury•Skull fracture•Focal neurological deficit•Coagulopathy•Post-traumatic seizures•Previous neurosurgery•Visual symptoms•Bicycle and pedestrian accident•Loss of consciousness•Vomiting•Severe or persistent headache•Amnesia•GCS < 14•Intoxication•Scalp hematoma/laceration
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Diffuse axonal injury (DAI) - mortality
Radiological (MRI)• Lesions of the hemispheres only: 14%• Unilateral lesions of the brainstems, deeper
lesions: 24%• Bilateral lesions of the pons with or without
any of the lesions of lesser grades: 100%
Firsching R, et al .Acta Neurochir. 2001.Weiss N, et al. Critical Care 2007.
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Diffuse Axonal Injury
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Minimal Protocol for MRI
• A 3-dimensional T1-weighted, preferable sagittal, sequence, which allows multiplanar reconstruction
• Axial T2-weighted sequence• Axial DWI sequence• Axial SWI sequence
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Spina Bifida
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Epidemiology
• 1/3rd of all congenital malformations
• 75% of fetal deaths
• 40% of deaths during the first year of life
• Cause not known in 75%
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Cutaneous manifestations
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Spina bifida occulta
• Sacral or lumbosacral is commonest
• Requires no treatment at birth
• Potential for the spinal cord to become fixed
(tethered) at the site of the lesion during
growth of child
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Meningocele
• Neurological function outcome is usually more
favorable
• Surgery to close the lesion
• Long-term needs will depend on the extent of
neurological deficits and level of involvement
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Myelomeningocele
• Apparent at birth
• Legs, bladder and bowel are usually affected
• Hydrocephalus is usually present
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Preoperative care
• Prevent infection– At the site of the lesion– Meningitis– Ventriculitis– Urinary infections
• Avoid drying and injury• Dressing– Clear Film– Non-abrasive– Non-adherent
Nurse proneMeticulous nappy care
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Surgery for open defects
• Within 24 hours of birth if no other life
threatening malformations
• Dissecting the neural tissue
• Covering the tissue with fibrous dura
• Skin graft may be necessary
• Shunt may be inserted
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Neurological care
• Correct positioning of the limbs
• Observation of the skin for any signs of pressure
damage
• Regular position changes
• Regular passive exercisesPerform above with other routines such as feeding
and nappy care
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Bladder care
• Continuous urine leakage or full bladder after voiding
• Regular renal ultrasound scans
• Intermittent catheterization
• Prophylactic antibioticsExpressing the bladder by applying pressure over the lower abdomen during nappy changes may increase the risk of
urinary reflux into the ureters
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Prevention
Before and during pregnancy
• Folic acid (0.4mg daily)
• Increase to 5mg daily for high risk women
• Avoid smoking and alcohol intake
• Avoid aminopterin, methotrexate, trimethoprim,
valproic acid, carbamazepine, and phenobarbitone
If not using contraceptives, take FOLIC ACID
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SCM