Common neurosurgical disorders in children


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  • Jain A, Sharma MC, Suri V, Kale SS, Mahapatra AK, Tatke M, et al. Spectrum of pediatric brain tumors in India: A multi-institutional study. Neurol India 2011;59:208-11
  • Wilne S, Collier J, Kennedy C, Koller K, Grundy R, Walker D. Presentation ofchildhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol. 2007 Aug;8(8):685-95.
  • Wilne S, Collier J, Kennedy C, Koller K, Grundy R, Walker D. Presentation ofchildhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol. 2007 Aug;8(8):685-95.
  • Jain A, Sharma MC, Suri V, Kale SS, Mahapatra AK, Tatke M, et al. Spectrum of pediatric brain tumors in India: A multi-institutional study. Neurol India 2011;59:208-11
  • Children with hydrocephalus face developmental disorders as they age. Hydrocephalus patients have reduced motor function, a lower-than-average adult IQ, and decreased visual function; they also are at risk for developing epilepsy.11 The extent of the complications observed is dependent upon the type of hydrocephalus, but patients with epileptic seizures (approximately 30%) have the worst clinical outcomes and, compared with patients who did not develop seizures, are more likely to have an IQ lower than 90.15 About 60% of children with hydrocephalus are able to attend school (although many have difficulties), and approximately 40% of children will lead relatively normal lives. - See more at:
  • a decreasing order of probability of intracranial injury, include depressed or basal skull fracture, focal neurological deficit, coagulopathy, post-traumatic seizures, previous neurosurgery, visual symptoms, bicycle and pedestrian motor vehicle accident, loss of consciousness, vomiting, severe or persistent headache, amnesia, GCS < 14, intoxication, and scalp hematoma/lacerationontroversy regarding the policy for hospital admission and evaluation with CT scan CT scan is desirable for children with MHI as it is useful for detection of a clinically significant intracranial lesion, prognostication, and decision for dischargeChildren with MHI and brain lesions on CT scan have greater impairment on cognitive testinghildren with normal CT scan after MHI can be discharged, and hospitalization is generally unnecessaryCT scan is not advisable for all children because of a remote risk of cancern a recent study on cancer due to CT scan, the authors found that the use of CT scans in children to deliver cumulative doses of about 50 mGy (i.e. 2-3 CT scans) almost tripled the risk of leukemia, and doses of about 60 mGy tripled the risk of malignant brain tumor. 
  • a Subcutaneous lipoma. b Subcutaneous lipoma associated with an angiomaand a dimple. c Tail. d“Queue de faune”. e-h Angiomas
  • Common neurosurgical disorders in children

    1. 1. Common Neurosurgical Problems in Children Dhaval Shukla Additional Professor of Neurosurgery NIMHANS, Bangalore
    2. 2. • Hydrocephalus • Congenital Malformations • Brain Tumors • Head injury
    3. 3. Brain Tumors • 20-30% of cancers in children • 2nd most common neoplasm • Most occur before age 10 years • Male/Female = 1.3/1.0
    4. 4. Symptoms in Small Children Macrocephaly 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%
    5. 5. Histological Types
    6. 6. Diagnosis
    7. 7. Treatment Tumor Type Surgery XRT Chemo Medulloblastoma +++ CrSp +++ Low grade astro +++ focal ---- cerebellar +++ ???? ---- optic glioma NO ???? ???? High grade astro/GBM +++ +++ ? Brain stem glioma (exophytic) focal ? Ependymoma +++ focal ---- Germ cell tumor ? bx +++ +++
    8. 8. Treatment - Surgery • In general, needed for diagnosis Exceptions: Germ cell, Brainstem • Ideal is gross total resection Balance prognosis vs. morbidity • Debulking, shunts, reservoirs - For symptom/ICP reduction, therapy
    9. 9. Survival Type 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%
    10. 10. 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
    11. 11. Large, Small, and Abnormal Head
    12. 12. • 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
    13. 13. Hydrocephalus
    14. 14. Hydrocephalus – Treatment Options
    15. 15. 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
    16. 16. 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)
    17. 17. 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
    18. 18. • Neuroendoscopy in Infants and the International Infant Hydrocephalus Study • BASICS trial: British antibiotic and silver- impregnated catheters for VP shunts
    19. 19. 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
    20. 20. 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
    21. 21. Craniostenosis
    22. 22. Craniostenosis
    23. 23. Craniostenosis • Surgery – Cosmesis – Brain Development • Extent of surgery – Conservative surgery in small children – Extensive cranial vault remodeling after 6 months • Complications – Blood loss – Hypothermia
    24. 24. Head Injury
    25. 25. Traumatic Brain Injury
    26. 26. 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
    27. 27. 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.
    28. 28. Diffuse Axonal Injury
    29. 29. 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
    30. 30. Spina Bifida
    31. 31. 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%
    32. 32. Cutaneous manifestations
    33. 33. 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
    34. 34. 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
    35. 35. Myelomeningocele • Apparent at birth • Legs, bladder and bowel are usually affected • Hydrocephalus is usually present
    36. 36. 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 prone Meticulous nappy care
    37. 37. 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
    38. 38. Neurological care • Correct positioning of the limbs • Observation of the skin for any signs of pressure damage • Regular position changes • Regular passive exercises Perform above with other routines such as feeding and nappy care
    39. 39. Bladder care • Continuous urine leakage or full bladder after voiding • Regular renal ultrasound scans • Intermittent catheterization • Prophylactic antibiotics Expressing the bladder by applying pressure over the lower abdomen during nappy changes may increase the risk of urinary reflux into the ureters
    40. 40. 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
    41. 41. SCM