Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy

2001 ◽  
Vol 95 (5) ◽  
pp. 791-797 ◽  
Author(s):  
Christian Sainte-Rose ◽  
Giuseppe Cinalli ◽  
Franck E. Roux ◽  
Wirginia Maixner ◽  
Paul D. Chumas ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Endoscopic Third Ventriculostomy ◽  
Tumor Resection ◽  
Third Ventriculostomy ◽  
Posterior Fossa Surgery ◽  
Posterior Fossa Tumors ◽  
Content Type ◽  
Group A ◽  
Group B ◽  
Fine Print

Object. The authors undertook a study to evaluate the effectiveness of endoscopic third ventriculostomy in the management of hydrocephalus before and after surgical intervention for posterior fossa tumors in children. Methods. Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hôpital Necker—Enfants Malades in Paris. Excluded were 10 patients in whom shunts had been placed at the referring hospital. The medical records and neuroimaging studies of the remaining 196 patients were reviewed and categorized into three groups: Group A, 67 patients with hydrocephalus present on admission in whom endoscopic third ventriculostomy was performed prior to tumor removal; Group B, 82 patients with hydrocephalus who did not undergo preliminary third ventriculostomy but instead received conventional treatment; and Group C, 47 patients in whom no ventricular dilation was present on admission. There were no significant differences between patients in Group A or B with respect to the following variables: age at presentation, evidence of metastatic disease, extent of tumor resection, or follow-up duration. In patients in Group A, however, more severe hydrocephalus was demonstrated (p < 0.01); the patients in Group C were in this respect different from those in the other two groups. Ultimately, there were only four patients (6%) in Group A compared with 22 patients (26.8%) in Group B (p = 0.001) in whom progressive hydrocephalus required treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence reported in the literature and significantly different from that demonstrated in Group A (p < 0.016). The other six patients (7.3%) were treated by endoscopic third ventriculostomy after tumor resection. In Group C, two patients (4.3%) with postoperative hydrocephalus underwent endoscopic third ventriculostomy. In three patients who required placement of CSF shunts several episodes of shunt malfunction occurred that were ultimately managed by endoscopic third ventriculostomy and definitive removal of the shunt. There were no deaths; however, there were four cases of transient morbidity associated with third ventriculostomy. Conclusions. Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. The procedure provides a valid alternative to placement of a permanent shunt in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions. Furthermore, in patients in whom CSF has caused spread of the tumor at presentation, third ventriculostomy allows chemotherapy to be undertaken prior to tumor excision by controlling hydrocephalus. Although the authors acknowledge that the routine application of third ventriculostomy in selected patients results in a proportion of patients undergoing an “unnecessary” procedure, they believe that because patients' postoperative courses are less complicated and because the incidence of morbidity is low and the success rate is high in those patients with severe hydrocephalus that further investigation of this protocol is warranted.

scholarly journals Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy

1999 ◽  
Vol 7 (4) ◽  
pp. E4 ◽  
Author(s):  
Christian Sainte-Rose ◽  
Giuseppe Cinalli ◽  
Franck E. Roux ◽  
Wirginia Maixner ◽  
Paul D. Chumas ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Pediatric Patients ◽  
Endoscopic Third Ventriculostomy ◽  
Third Ventriculostomy ◽  
Posterior Fossa Surgery ◽  
Tumor Removal ◽  
Posterior Fossa Tumors ◽  
Group A ◽  
Postoperative Hydrocephalus ◽  
Group B

The authors conducted a study to evaluate the effectiveness of endoscopically guided third ventriculostomy in the pre- and postoperative management of hydrocephalus in pediatric patients who harbored posterior fossa tumors. Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hôpital Necker-Enfants Malades in Paris. Ten patients in whom shunts were implanted at the referring hospital were excluded. The medical records and neuroimaging studies obtained in the remaining 196 patients were reviewed. These patients were categorized into three groups: 67 patients with hydrocephalus on admission in whom endoscopically guided third ventriculostomy was performed prior to tumor removal (Group A); 82 patients with hydrocephalus in whom preliminary third ventriculostomy was not performed and who were managed in a “conventional way” (Group B); and 47 patients without ventricular dilation on admission (Group C). There was no significant difference between Group A and Group B patients with respect to age at presentation, evidence of metastatic disease, degree of tumor resection, or follow up. In the patients in Group A, however, more severe hydrocephalus was present (p < 0.01). Patients in Group C were, in this respect, different from the other two groups. Ultimately, only four patients (6%) in Group A as compared with 22 patients (27 %) in Group B (p = 0.001) had progressive hydrocephalus requiring treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence of this procedure reported in the literature and significantly different from that in Group A (p < 0.016). The other six patients in Group B (6%) were treated by endoscopically guided third ventriculostomy after tumor removal. In Group C, two patients (4%) with postoperative hydrocephalus underwent endoscopically guided third ventriculostomy. In three of the patients who required placement of cerebrospinal fluid shunts several episodes of shunt malfunction occurred; these were ultimately managed by performing endoscopic third ventriculostomy and definitive removal of the shunt. There were no cases of death and four cases of transient morbidity associated with the ventriculostomy. Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. Furthermore, it provides a valid alternative to the placement of permanent shunts in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions. Although the authors acknowledge that the routine application of third ventriculostomy in selected patients may result in a proportion of patients undergoing an “unnecessary” procedure, they believe that because of patients' less complicated postoperative course, the low morbidity rate, and the high success rate of third ventriculostomy, further investigation of this protocol is warranted.

The pathophysiology of oral pharyngeal apraxia and mutism following posterior fossa tumor resection in children

1995 ◽  
Vol 83 (3) ◽  
pp. 467-475 ◽  
Author(s):  
Andrew T. Dailey ◽  
Guy M. McKhann ◽  
Mitchel S. Berger
Keyword(s):  
Posterior Fossa ◽  
Pediatric Patients ◽  
Tumor Resection ◽  
Posterior Fossa Tumor ◽  
Posterior Fossa Tumors ◽  
Lower Cranial Nerve ◽  
Content Type ◽  
Cranial Nerve Function ◽  
Pharyngeal Musculature ◽  
Fine Print

✓ Mutism following posterior fossa tumor resection in pediatric patients has been previously recognized, although its pathophysiology remains unclear. A review of the available literature reveals 33 individuals with this condition, with only a few adults documented in the population. All of these patients had large midline posterior fossa tumors. To better understand the incidence and anatomical substrate of this syndrome, the authors reviewed a 7-year series of 110 children who underwent a posterior fossa tumor resection. During that time, nine (8.2%) of the 110 children exhibited mutism postoperatively. They ranged from 2.5 to 20 years of age (mean 8.1 years) and became mute within 12 to 48 hours of surgery. The period of mutism lasted from 1.5 to 12 weeks after onset: all children had difficulty coordinating their oral pharyngeal musculature as manifested by postoperative drooling and inability to swallow. Further analysis of these cases revealed that all children had splitting of the entire inferior vermis at surgery, as confirmed on postoperative magnetic resonance studies. Lower cranial nerve function was intact in all nine patients. Current concepts of cerebellar physiology emphasize the importance of the cerebellum in learning and language. The syndrome described resembles a loss of learned activities, or an apraxia, of the oral and pharyngeal musculature. To avoid the apraxia, therefore, the inferior vermis must be preserved. For large midline tumors that extend to the aqueduct, a combined approach through the fourth ventricle and a midvermis split may be used to avoid injuring the inferior vermis.

Preirradiation chemotherapy including “eight drugs in 1 day” regimen and high-dose methotrexate in childhood medulloblastoma: results of the M7 French Cooperative Study

1995 ◽  
Vol 82 (4) ◽  
pp. 608-614 ◽  
Author(s):  
J. C. Gentet ◽  
E. Bouffet ◽  
F. Doz ◽  
P. Tron ◽  
H. Roche ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Posterior Fossa ◽  
High Dose ◽  
High Dose Methotrexate ◽  
Content Type ◽  
Dose Methotrexate ◽  
Group A ◽  
Group B ◽  
The Brain ◽  
Fine Print

✓ The aim of this study was to evaluate the feasibility and efficacy of a protocol that includes “sandwich” chemotherapy, that is, chemotherapy alternated with radiotherapy, and reduced doses of supratentorial irradiation in children with medulloblastoma. Between March 1985 and September 1988, 70 successive children with newly diagnosed medulloblastoma from eight centers were treated in this prospective nonrandomized study. Patients were assigned to two risk groups. Group A included patients with macroscopically complete or subtotal excision, no brainstem involvement, no atypical cells in the cerebrospinal fluid, normal myelography, and who were more than 2 years of age. Group B patients encompassed those who did not fit the criteria for Group A. Two children were excluded from analysis after histological review confirmed ependymoma. Thus, a population of 68 children was selected, with 31 in Group A and 37 in Group B. Treatment consisted of two courses of the “eight drugs in 1 day” (“8/1”) regimen followed by two courses of high-dose methotrexate (12 g/m2). Radiotherapy was begun during the 7th week after surgery in Group A and during the 5th week in Group B. In patients older than 2 years, the median radiation dose to the posterior fossa, the spinal axis, and the brain was 54 Gy, 36 Gy, and 27 Gy, respectively. Group B patients received postirradiation chemotherapy with four 8/1 courses monthly. The median time from surgery to radiation therapy was 50 days (range 21 to 141 days). One fatality due to chicken pox on Day 102 and one World Health Organization Grade IV infection occurred. The estimated 5- and 7-year disease-free survival (DFS) rates were 62% and 59%, respectively. These were 74% and 62% in Group A and 57% and 57% in Group B. Patient age, extent of resection, and radiation dose to the whole brain had no prognostic value. Patients with metastasis had a nonsignificant trend for a worse prognosis than patients with nonmetastatic disease (7-year DFS 45% vs. 68%, p = 0.11). In Group B, the 7-year DFS rates for children who received more or less than 30 Gy to the brain were 69% and 52% respectively (p = 0.15). There were recurrences in the posterior fossa (37%), spine (20%), and brain (20%). After a review of radiotherapeutic treatments, only one supratentorial failure could be blamed on reduction of the supratentorial radiation dose. This “sandwich” chemotherapy appeared to be feasible and did not show adverse survival data when compared to other series.

Beta—tricalcium phosphate as a substitute for autograft in interbody fusion cages in the canine lumbar spine

2002 ◽  
Vol 97 (3) ◽  
pp. 350-354 ◽  
Author(s):  
Takashiro Ohyama ◽  
Yoshichika Kubo ◽  
Hiroo Iwata ◽  
Waro Taki
Keyword(s):  
Lumbar Spine ◽  
Tricalcium Phosphate ◽  
Interbody Fusion ◽  
Donor Site ◽  
Posterolateral Approach ◽  
Content Type ◽  
Spine Model ◽  
Group A ◽  
Group B ◽  
Fine Print

Object. An interbody fusion cage has been introduced for cervical anterior interbody fusion. Autogenetic bone is packed into the cage to increase the rate of union between adjacent vertebral bodies. Thus, donor site—related complications can still occur. In this study a synthetic ceramic, β—tricalcium phosphate (TCP), was examined as a substitute for autograft bone in a canine lumbar spine model. Methods. In 12 dogs L-1 to L-4 vertebrae were exposed via a posterolateral approach, and discectomy and placement of interbody fusion cages were performed at two intervertebral disc spaces. One cage was filled with autograft (Group A) and the other with TCP (Group B). The lumbar spine was excised at 16 weeks postsurgery, and biomechanical, microradiographic, and histological examinations were performed. Both the microradiographic and histological examinations revealed that fusion occurred in five (41.7%) of 12 operations performed in Group A and in six (50%) of 12 operations performed in Group B. The mean percentage of trabecular bone area in the cages was 54.6% in Group A and 53.8% in Group B. There were no significant intergroup differences in functional unit stiffness. Conclusions. Good histological and biomechanical results were obtained for TCP-filled interbody fusion cages. The results were comparable with those obtained using autograft-filled cages, suggesting that there is no need to harvest iliac bone or to use allo- or xenografts to increase the interlocking strength between the cage and vertebral bone to achieve anterior cervical interbody fusion.

Prevention of postoperative posterior tethering of spinal cord after resection of ependymoma

2003 ◽  
Vol 99 (2) ◽  
pp. 181-187 ◽  
Author(s):  
Takeo Goto ◽  
Kenji Ohata ◽  
Toshihiro Takami ◽  
Misao Nishikawa ◽  
Akimasa Nishio ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Neurological Deterioration ◽  
Fisher Exact Test ◽  
Content Type ◽  
Exact Test ◽  
Spinal Ependymoma ◽  
Group A ◽  
Delayed Neurological Deterioration ◽  
Group B ◽  
Fine Print

Object. The authors evaluated an alternative method to avoid postoperative posterior tethering of the spinal cord following resection of spinal ependymomas. Methods. Twenty-five patients with spinal ependymoma underwent surgery between 1978 and 2002. There were 16 male and nine female patients whose ages at the time of surgery ranged from 14 to 64 years (mean 41.8 years). The follow-up period ranged from 6 to 279 months (mean 112.4 months). In the initial 17 patients (Group A), the procedure to prevent arachnoidal adhesion consisted of the layer-to-layer closure of three meninges and laminoplasty. In the subsequently treated eight patients (Group B), the authors performed an alternative technique that included pial suturing, dural closure with Gore-Tex membrane—assisted patch grafting, and expansive laminoplasty. In Group A, postoperative adhesion was radiologically detected in eight cases (47%), and delayed neurological deterioration secondary to posterior tethering of the cord was found in five cases. In Group B, there was no evidence of adhesive posterior tethering or delayed neurological deterioration. A significant intergroup statistical difference was demonstrated for radiologically documented posterior tethering (p < 0.05, Fisher exact test). Moreover, patients with radiologically demonstrated posterior tethering suffered a significant delayed neurological functional deterioration (p < 0.01, Fisher exact test). Conclusions. This new technique for closure of the surgical wound is effective in preventing of postoperative posterior spinal cord tethering after excision of spinal ependymoma.

A positron emission tomography study of cerebrovascular reserve before and after shunt surgery in patients with idiopathic chronic hydrocephalus

1999 ◽  
Vol 91 (4) ◽  
pp. 605-609 ◽  
Author(s):  
Petra M. Klinge ◽  
Georg Berding ◽  
Thomas Brinker ◽  
Wolfram H. Knapp ◽  
Madjid Samii
Keyword(s):  
Positron Emission Tomography ◽  
Emission Tomography ◽  
Chronic Hydrocephalus ◽  
Content Type ◽  
Cerebrovascular Reserve ◽  
Shunt Placement ◽  
Positron Emission ◽  
Group A ◽  
Group B ◽  
Fine Print

Object. In this study the authors use positron emission tomography (PET) to investigate cerebral blood flow (CBF) and cerebrovascular reserve (CVR) in chronic hydrocephalus.Methods. Ten patients whose mean age was 67 ± 10 years (mean ± standard deviation [SD]) were compared with 10 healthy volunteers who were 25 ± 3 years of age. Global CBF and CVR were determined using 15O—H2O and PET prior to shunt placement and 7 days and 7 months thereafter. The CVR was measured using 1 g acetazolamide. Neurological status was assessed based on a score assigned according to the methods of Stein and Langfitt.Seven months after shunt placement, five patients showed clinical improvement (Group A) and five did not (Group B). The average global CBF before shunt deployment was significantly reduced in comparison with the control group (40 ± 8 compared with 61 ± 7 ml/100 ml/minute; mean ± SD, p < 0.01). In Group A the CBF values were significantly lower than in Group B (36 ± 7 compared with 44 ± 8 ml/100 ml/minute; p < 0.05). The CVR before surgery, however, was not significantly different between groups (Group A = 43 ± 21%, Group B = 37 ± 29%). After shunt placement, there was an increase in the CVR in Group A to 52 ± 37% after 7 days and to 68 ± 47% after 7 months (p < 0.05), whereas in Group B the CVR decreased to 14 ± 18% (p < 0.05) after 7 days and returned to the preoperative level (39 ± 6%) 7 months after shunt placement.Conclusions. The preliminary results indicate that a reduced baseline CBF before surgery does not indicate a poor prognosis. Baseline CBF before shunt placement and preoperative CVR are not predictive of clinical outcome. A decrease in the CVR early after shunt placement, however, is related to poor late clinical outcome, whereas early improvement in the CVR after shunt placement indicates a good prognosis.

Ventriculoperitoneal Shunt versus Endoscopic Third Ventriculostomy in the treatment of Obstructive Hydrocephalus in Pediatric Midline Posterior Fossa tumors

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Mohammed Tarek ◽  
Hamdy Ibrahim ◽  
H Jalalod'din ◽  
SR Tawadros
Keyword(s):  
Posterior Fossa ◽  
Ventriculoperitoneal Shunt ◽  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Clinical Findings ◽  
Third Ventriculostomy ◽  
Posterior Fossa Tumors ◽  
Shunt Insertion ◽  
Vp Shunt ◽  
Csf Diversion

Abstract Background Treatment of secondary hydrocephalus due to posterior fossa tumors in these children is still a matter of controversy, although preoperative ventriculo-peritoneal shunt (VP shunt) insertion before tumor excision is widely accepted among neurosurgeons but many attempts are rising to minimize permanent VP shunt insertion and associated complications and introducing third endoscopic ventriculostomy (ETV) as one of the options of 2ry hydrocephalus. Objectives Comparing the post-operative clinical success with resolution of the manifestations and post-operative complications between endoscopic third ventriculostomy and ventriculoperitoneal shunt as different modes of CSF diversion in children with 2ry hydrocephalus due to midline posterior fossa tumors. Methods The following electronic databases were searched from June 2009 to june2019: PubMed, Google scholar search engine. Cochrane database of systematic reviews, EMBASE and science Direct, using the keywords ―hydrocephalus; posterior fossa tumors; pediatrics; ventriculoperitoneal shunt; endoscopic third ventriculostomy‖. Studies were eligible if they contain the target keywords in title or abstract, addressing the Pediatric age group with 2ry hydrocephalus due to de novo posterior fossa tumor manifested by signs of increase the intra cranial tension including persistent headache and vomiting, blurred vision, 6th nerve palsy, papilledema in fundus examination, acute DCL and 2ry hydrocephalus confirmed by brain imaging. Exclusion criteria included studies including age group below 1yr or above 18 yr, or patients with recurrent post fossa tumors and operated before or patients presented by failed previously attempt of CSF diversion. Results: A total of 1255 citations were screened for eligibility,6 studies were included in our systematic review discussing, comparing and evaluating the durability of ETV versus VP shunt in treatment the 2ry hydrocephalusdue to pediatric posterior fossa tumor.. Overall study population reached 474 patients. the overall clinical findings at presentation and postoperative outcomes regarding the clinical findings improvement, radiological improvement and postoperative complications between ETV and VP shunt are compared and showing that ETV should be considered as an alternative procedure to VP shunt in controlling severe hydrocephalus related to posterior fossa tumors to relieve symptoms quickly during the preoperative period when patients should wait for their definite tumor excision. Conclusion The shorter duration of surgery, the lower incidence of morbidity, the absence of mortality, the lower incidence of procedure failure of endoscopic third ventriculostomy as compared to ventriculoperitoneal shunt, and the significant advantage of not becoming shunt dependent make endoscopic third ventriculostomy to be recommended as the first choice in the treatment of pediatric patients with marked obstructive hydrocephalus due to posterior fossa tumors. It is a preliminary, simple, safe, effective, physiological, minimally invasive procedure for the relief of elevated intracranial pressure before direct tumor removal.

Endoscopic Third Ventriculostomy in the Treatment of Hydrocephalus Associated with Posterior Fossa Tumors in Children

Neurosurgery ◽  
1999 ◽  
Vol 45 (3) ◽  
pp. 734-735
Author(s):  
F. E. Roux ◽  
G. Cinalli ◽  
C. Sainte-Rose ◽  
P. Chumas ◽  
M. Zerah ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Endoscopic Third Ventriculostomy ◽  
Third Ventriculostomy ◽  
Posterior Fossa Tumors

Use of ligamentum nuchae graft for dural closure in posterior fossa surgery

1998 ◽  
Vol 89 (1) ◽  
pp. 155-156 ◽  
Author(s):  
Edward J. Kosnik
Keyword(s):  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Cerebrospinal Fluid Leakage ◽  
Posterior Fossa Surgery ◽  
Content Type ◽  
Fluid Leakage ◽  
Dural Closure ◽  
Fine Print

✓ The technique of harvesting the ligamentum nuchae and its use in posterior fossa surgery are discussed. By using this technique the author has avoided postoperative cerebrospinal fluid leakage in more than 200 procedures.

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