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A multiple shunt system has been employed in nine children with hydrocephalus combined with absent or insufficient communication with intracranial-filled spaces. The common feature of the different lesions to such a shunt system is a pressure difference, which can be adjusted by this procedure. There arise four general indications: (1) the uniform drainage of CSF spaces which do not communicate with each other; (2) the uniform drainage of CSF and other separate liquid filled intracranial spaces; (3) to obtain gradual and steady diminution of enormously dilated CSF or other fluid-filled spaces; (4) the use of both sides for shunting in cases with recurrent failures of a unilateral drainage. The post-operative efficacy of a multiple shunt can be proved by demonstrating evenly decreasing CSF and other fluid-filled cavities, and by equilibrium between their different pressures. Evaluation of possible shunt failure in a multiple system requires CT and ICP recordings.

We report a series of infants with optic chiasmal hypothalamic astrocytomas (OCHAs) who developed abdominal ascites following ventriculo-peritoneal (VP) shunting. The mechanism of ascites development among these patients with OCHA remains speculative and unclear. We treated four infants with hypothalamic tumors who were shunted for hydrocephalus using standard VP shunts and who subsequently experienced symptomatic ascites. In three patients the gallbladder proved an effective alternative site for shunting prior to conversion to other sites, and in one patient the gallbladder shunt remains functional and revision-free. Several aspects of the gallbladder as a reservoir for CSF make this approach appealing. Ventricular gallbladder shunting provided an effective (at least temporarily) receptacle for CSF in these patients.

Congenital brain tumors, especially tumors diagnosed before birth, are very rare. This report presents a case of a congenital gemistocytic astrocytoma diagnosed by antenatal intrauterine ultrasound. An intrauterine MRI revealed hydrocephalus and a mass lesion including massive hemorrhage in the right occipital lobe of a fetus. The patient was delivered by cesarean section and a total excision of the hemorrhagic tumor was carried out on the third day of his life. The histological study revealed gemistocytic astrocytoma (WHO grade II). Neither adjuvant chemotherapy nor radiation was given after the first surgery. Ten months after his birth, a recurrent tumor was depicted on follow-up MRI. The second total excision of the recurrent tumor and chemotherapy using cisplatin and vincristine were performed. The patient is free of disease at the age of 2 years and 6 months.

In the management of craniosynostosis, there is a need for quantitative assessment of treatment methods and outcome. Radiology and pressure studies are well documented, but so far little attention has been given to cerebral blood flow changes and their possible relevance. This paper reports our initial experience using transcranial Doppler sonography to calculate the cerebrovascular resistance and cerebral blood velocities in the major basal vessels before and after surgery for craniosynostosis. Ten patients were studied using the Scimed 2-MHz probe through the temporal and frontal “windows” of the skull. Measurements were taken under standard physiological conditions before, during and after surgery. Preliminary results suggest that this non-invasive technique may be helpful in predicting and assessing the outcome following surgery for craniosynostosis.

Two children with diastematomyelia were diagnosed before operation with high-resolution spinal ultrasonography. Neonates with evident or suspected diastematomyelia can be effectively examined by high-resolution spinal ultrasonography and spinal radiography, reserving more invasive techniques for those for whom the method proves inadequate.

Thalamic tumors (TT) merit individual analysis and must not be confused with tumors that, while involving the entire thalamus have a different origin. We analyzed 26 patients who fulfilled our criteria of having ``strictly'' TT. We examined incidence, clinical features, histology, response to treatment (mainly surgery), recurrence rate, mortality and prognosis. We considered that histology and surgical treatment were the most important items related to prognosis. Low-grade tumors (LGT) had a good prognosis, while anaplastic tumors (AT) had a discouraging one; nevertheless both must be operated on. We believe that total removal of LGT is curative and total removal of AT, even if it is not curative, can extend survival by some months. Radiotherapy and chemotherapy seemed to be of little value in our series of TT.

Intraosseous (IO) vascular access has been used since the Second World War and is warranted when there is an emergency and/or urgent need to replenish the vascular pool. Despite long-term and satisfactory results from delivering large quantities of intravenous fluid via the medullary space of bone, use of this space for a distant receptacle for cerebrospinal fluid (CSF) diversion has seldom been considered. The current paper reviews the literature regarding the bony medullary space as a receptacle for intravenous fluid and CSF. Previous authors have demonstrated the potential of the diploic space of the calvaria for CSF shunting. Pugh and colleagues tested the ability of the cranium to receive and absorb a small amount of tracer fluid. The literature suggests that intraosseous placement of ventricular diversionary shunts is an alternative to more traditional sites such as the pleural cavity and peritoneum. When these latter locations are not available or are contraindicated, placement in the medullary space of bone is another option available to the surgeon.