Springer Science and Business Media LLC

Abnormal cerebrospinal fluid (CSF) dynamics can produce a number of significant clinical problems to include hydrocephalus, loculated areas within the ventricles or subarachnoid spaces as well as impairment of normal CSF movement between the cranial and spinal compartments that can result in a cerebellar ectopia and hydrosyringomyelia. Thus, assessing the patency of fluid flow between adjacent CSF compartments non-invasively by magnetic resonance imaging (MRI) has definite clinical value. Our objective was to demonstrate that a novel tag-based CSF imaging methodology offers improved contrast when compared with a commercially available application. In a prospective study, ten normal healthy adult subjects were examined on 3T magnets with time-spatial labeling inversion pulse (Time-SLIP) and a new tag-based flow technique—time static tagging and mono-contrast preservation (Time-STAMP). The image contrast was calculated for dark-untagged CSF and bright-flowing CSF. We tested the results with the D’Agostino and Pearson normality test and Friedman’s test with Dunn’s multiple comparison correction for significance. Separately 96 pediatric patients were evaluated using the Time-STAMP method. In healthy adults, contrasts were consistently higher with Time-STAMP than Time-SLIP (p < 0.0001, in all ROI comparisons). The contrast between untagged CSF and flowing tagged CSF improved by 15 to 34%. In both healthy adults and pediatric patients, CSF flow between adjacent fluid compartments was demonstrated. Time-STAMP provided images with higher contrast than Time-SLIP, without diminishing the ability to visualize qualitative CSF movement and between adjacent fluid compartments.

Endoscopic third ventriculostomy (ETV) has become first-line treatment for obstructive hydrocephalus. Many complications have been described, but the literature about oculomotor palsy after ETV is scarce. Therefore we undertook an anatomical study of the relationship of the oculomotor nerve to the floor of the third ventricle. Distances and angles between the third nerve and the bottom of the third ventricle were studied both in two cadaver heads and in high-definition CISS images in 16 MRI scans. The angles of the trajectories putting the nerve at risk or not were compared. Finally, in a retrospective analysis of intraoperative images the appearance of the membranous portion of the floor was defined and if visible, the distance of the third nerve to the midline was estimated by comparing with the 8-mm balloon catheter. The course of the third nerve is approximately 8 mm laterally and approximately 17 mm caudally distant from the midpoint of the floor of the third ventricle. The angle of the trajectory to damage the third nerve is at least 12° greater than any safe angle of ETV trajectory through a normal burr hole. The third nerve is not always visible during ETV procedures, but the angular and linear measurements imply that the risk to damage the nerve should be relatively small. Confirmation of these data in hydrocephalic patients with distorted anatomy is needed.

Hydrocephalus is a common presenting symptom of pediatric posterior fossa tumors and often requires permanent cerebrospinal fluid diversion even after resection. Endoscopic third ventriculostomy (ETV) is a well-established treatment of obstructive hydrocephalus in children. The objective of this study is to demonstrate that ETV prior to posterior fossa tumor resection decreases the rate of postoperative ventriculoperitonal shunt (VPS) placement. We performed a retrospective analysis of patients who presented with hydrocephalus and underwent posterior fossa tumor resection between 2005 and 2016 excluding pineal and tectal tumors. The rate of postoperative VPS placement was compared in patients who underwent resection and had a VPS placed perioperatively (historical controls) with patients who underwent ETV prior to resection. The two groups were matched for demographics, tumor histology, and tumor location. We also performed a literature review of prior studies that examined the role of ETV in pediatric posterior fossa tumors. Thirty-six patients in the control group were compared to 38 patients in our study. The patients were matched across all variables (age, gender, tumor histology, and tumor locations). The rate of postoperative VPS placement was 31% in the control group compared to 16% in the ETV group. No complications were encountered during ETV. Endoscopic third ventriculostomy prior to posterior fossa tumor resection in children appears to decrease the rate of postoperative VPS placement. Given its efficacy and safety, ETV should be considered prior to tumor resection in these patients.

We reviewed the results of all pediatric patients undergoing intracranial pressure (ICP) monitoring in a 2-year period at our institution. The outcome of patients suffering hypoxia or ischemic injuries (HII) is compared to those suffering non-hypoxic or non-ischemic injuries (NHII). Thirty-four patients had ICP monitors placed during the study period. Inconplete patient information led to the exclusion of 5 patients. An additional 5 patients were excluded because no measures to control ICP were taken after the monitor was placed. Twenty-four patients required treatment for raised ICP (hyperventilation, 24; mannitol, 19; barbiturate coma, 6). Admission Glasgow Coma Score in patients suffering HII (median score 5) and NHII (median score 6) were not significantly different (Mann-Whitney U Test). Only 2 of 8 patients with HII were near-drowning vietims. The remaining 6 had HII from other causes (5 survivors of various forms of asphyxia and 1 of cardiac arrest). All 8 patients had poor outcomes (1 severely disabled; 7 died). The 16 patients with NHII had a variety of diagnoses (6 trauma, 5 encephalitis, 4 bacterial meningitis, 1 diabetic ketoacidosis). Among these, 6 had good outcomes and 10 poor outcomes (2 severely disabled, 2 vegetative, and 6 died). The difference in outcome between patients with NHII and HII is significant at P=0.059 (Fischer Exact test). Patients with NHII may benefit from ICP monitoring. Patients with HII from near-drowning and other causes did not appear to benefit from ICP monitoring and interventions directed at controlling ICP.

A Japanese male infant with lissencephaly, congenital muscular dystrophy (CMD), and ocular abnormalities is described. This patient represents features of the cerebro-oculo-muscular syndrome. Cranial computerized tomography revealed diffuse agyria, low density of the white matter, and hypoplasia of the cerebellar vermis. Brain histology suggested type II lissencephaly. These findings are correlated with other similar conditions, such as Walker-Warburg syndrome, Fukuyama-type CMD, and muscle, eye and brain disease.

The availability of magnetic resonance imaging (MRI) has resulted in an increasing number of asymptomatic, minimally symptomatic, and doubtfully symptomatic patients being diagnosed with a Chiari I malformation with or without syringomyelia. In an attempt to clarify how neurosurgeons manage these clinical problems, an international survey on the Chiari I malformation and related syringomyelia was undertaken. A questionnaire on the expected natural course of the disease and on aspects of the surgical technique for a number of hypothetical cases relating to Chiari I malformation with and without syringomyelia was used to survey Pediatric Neurosurgeons worldwide. Of 246 questionnaires distributed, 76 (30.8%) were completed and returned. There was a consensus that no operation should be carried out in asymptomatic patients with a Chiari I malformation, unless there is associated syringomyelia. There was a consensus that decompression of the Chiari malformation should be performed in patients with scoliosis when syringomyelia is present, and the majority decompressed the Chiari malformation in scoliotic patients even in the absence of syringomyelia. Suboccipital decompression was the standard surgical procedure for Chiari I malformations. The majority of respondents favored routine dural opening at surgery and closure with a pericranial or synthetic patch graft. In the case of a persistent or progressive syrinx after suboccipital decompression, the majority recommended shunting of the syrinx to the subarachnoid space or to the pleural cavity. There continues to be much variation in the management of the Chiari I malformation.

A possible benefit of endoscopic third ventriculostomy (ETV) is that families might harbor less concern and anxiety compared to shunt. This has not yet been demonstrated, however. Our goal was to compare parental concern in a large sample of children with hydrocephalus treated with ETV or shunt, using our previously developed measure of parental concern, the Hydrocephalus Concerns Questionnaire for Parents (HCQ-P). The parents of children 5–18 years old with previously treated hydrocephalus at three Canadian pediatric neurosurgery centers completed the HCQ-P. HCQ-P scores were compared between those who were initially treated with ETV and those initially treated with shunt. A multivariable linear regression analysis was used to adjust for center, current age, age at initial hydrocephalus surgery, seizures, etiology, hydrocephalus complications, and quality of life. Six hundred three families participated (58 ETV [9.6%], 545 shunt [90.4%]). In unadjusted comparison, ETV parents had lower overall concern (HCQ-P = 0.41 versus 0.51, p = 0.02). After adjustment for multiple patient factors, ETV parents still had lower concern (p = 0.03) but the only questions for which there was a still a statistically significant difference were those related to concerns about shunt/ETV complications. Parents of children who have had ETV experience less concern than those who have had shunt and this is due almost exclusively to less concern about hydrocephalus treatment complications. While this could be interpreted as a beneficial aspect of ETV treatment, it remains important for neurosurgeons to ensure that parents are not being overly complacent about the possibility of ETV failure requiring urgent treatment.