Common Neurosurgical Problems in Children

Dhaval ShuklaAdditional Professor of Neurosurgery

NIMHANS, Bangalore

• Hydrocephalus

• Congenital Malformations

• Brain Tumors

• Head injury

Brain Tumors• 20-30% of cancers in children• 2nd most common neoplasm• Most occur before age 10 years• Male/Female = 1.3/1.0

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%

Histological Types

Diagnosis

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 +++ +++

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

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%

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

Large, Small, and Abnormal Head

• 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

Hydrocephalus

Hydrocephalus – Treatment Options

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

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)

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

• Neuroendoscopy in Infants and the International Infant Hydrocephalus Study

• BASICS trial: British antibiotic and silver-impregnated catheters for VP shunts

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

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

Craniostenosis

Craniostenosis

Craniostenosis

• Surgery– Cosmesis– Brain Development

• Extent of surgery– Conservative surgery in small children– Extensive cranial vault remodeling after 6 months

• Complications– Blood loss– Hypothermia

Head Injury

Traumatic Brain Injury

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

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.

Diffuse Axonal Injury

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

Spina Bifida

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%

Cutaneous manifestations

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

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

Myelomeningocele

• Apparent at birth

• Legs, bladder and bowel are usually affected

• Hydrocephalus is usually present

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

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

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

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

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

SCM