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This is a case report of a child with double neural tube defect (NTD) comprising a parietal encephalocoele and an open thoracic myelomeningocoele. The authors use this case to endorse the multi-site neural tube closure theory as aetiology for all multiple NTDs. Proponents of this theory claim that neural tube defects occur at “collision sites” of neural tube closure with opposing closure directions, and because up to five or six of these waves are thought to be operational, there are, accordingly, multiple collision sites. The multi-site closure theory was used originally to explain the different favoured locations of encephalcoeles, and as such, the theory is seductive. At collision sites, the overlying myocutaneous tissues may be potentially weaker and, therefore, susceptible to being stretched but not disrupted by a focal herniation of the alar plates of the already closed cranial neural tube and surrounding meninges. The disorganised gyral development and cortical dysplasia of the herniated brain may be secondary to early tissue distortion. The overlying skin and meninges are intact. Spinal open neural tube defects (ONTD) are due to focal absence of neural plate closure, as shown in numerous, very credible animal experiments. The skin, muscles, neural arches and dura are wide open, and the exposed neural material is an unfused neural plate. This true “closure lesion” is thus fundamentally different from a “collision lesion” exemplified by the encephalocoele. Most spinal ONTDs are terminal lesions involving the end of the primary neural tube, but there are rare examples of segmental lesions in which the “suspended” open neural placode is flanked by normal spinal cord both rostrally and caudally. The incomplete neural plate closure occurs in a square-pulse fashion followed by resumption of normal closure. Three percent of ONTDs in our unit are segmental placodes. Most hemi-myelomeningocoeles associated with split cord malformation (SCM) are segmental lesions. Limited dorsal myeloschisis (LDM), though not technically “open”, is a segmental neural tube closure abnormality, as is dorsal lipoma, a lesion of segmental premature disjunction. If there can be one segmental closure failure, why not two or even three square pulse insults, separated in time, causing in tandem closure lesions resulting in either two segmental ONTDs or one segmental and one terminal ONTD? Other multiple neural tube closure abnormalities, though rare, have been reported, such as double LDMs, double dorsal lipomas and double dermal sinus tracts. Even double SCMs caused by multi-focal gastrulation defects with multiple endomeschymal tracts are well known in the literature. Thus, multiple spinal ONTDs can conceivably occur without invoking the multiple closure-wave theory, which, in the spinal cord will produce a very different lesion. It is not known why there should be abrupt recovery of normal neural tube closure after the square pulse insult. There could conceivably be transient presence of a teratogenic impulse that disturbs certain downstream transcription factors, without a fixed genomic mutation that would perpetuate the developmental error. It is thus the timing of the next transient insult that determines the location of the second neural tube defect, rather than the activities of the colliding zippers.

Objects Deliberate termination of life of newborns (involuntary euthanasia) with meningomyelocele (MMC) is practiced openly only in the Netherlands. ‘Unbearable and hopeless suffering’ is the single most cited criterion for this termination, together with the notion that ‘there are no other proper medical means to alleviate this suffering’. In this paper, both (and other) statements are questioned, also by putting them in a broader perspective. Methods First, a historical overview of the treatment of newborns with MMC is presented, concentrating on the question of selection for treatment. Second, a thorough analysis is made of the criteria used for life termination. Third, a case of a newborn with a very severe MMC is presented as a ‘reference case’. Conclusion ‘Unbearable and hopeless suffering’ cannot be applied to newborns with MMC. They are not ‘terminally ill’ and do have ‘prospects of a future’. In these end-of-life decisions, ‘quality of life judgments’ should not be applied. When such a newborn is not treated, modern palliative care always will suffice in eliminating possible discomfort. There is no reason whatsoever for active life-termination of these newborns.

Objective The purpose of this study was to review the epidemiology and the clinical, radiological, pathological, and follow-up data of all surgically treated pediatric meningiomas during the last 35 years in The Netherlands. Methods Patients were identified in the Pathological and Anatomical Nationwide Computerized Archive database, the nationwide network and registry of histopathology and cytopathology in The Netherlands. Pediatric patients of 18 years or younger at first operation in 1974–2009 with the diagnosis meningioma were included. Clinical records, follow-up data, radiological findings, operative reports, and pathological examinations were reviewed. Results In total, 72 patients (39 boys) were identified. The incidence of operated meningiomas in the Dutch pediatric population is 1:1,767,715 children per year. Median age at diagnosis was 13 years (range 0–18 years). Raised intracranial pressure and seizures were the most frequent signs at presentation. Thirteen (18 %) patients had neurofibromatosis type 2 (NF2). Fifty-three (74 %) patients had a meningioma World Health Organization grade I. Total resection was achieved in 35 of 64 patients. Fifteen patients received radiotherapy postoperatively. Mean follow-up was 4.8 years (range 0–27.8 years). Three patients died as a direct result of their meningioma within 3 years. Four patients with NF2 died as a result of multiple tumors. Nineteen patients had disease progression, requiring additional treatment. Conclusion Meningiomas are extremely rare in the pediatric population; 25 % of all described meningiomas show biological aggressive behavior in terms of disease progression, requiring additional treatment. The 5-year survival is 83.9 %, suggesting that the biological behavior of pediatric menigiomas is more aggressive than that of its adult counterparts.

Purpose We conducted this study to gauge the health-related problems, quality of life and the performance of the Health Utility Index Mark 3 (HUI-3) in patients with syndromic and complex craniosynostosis. Patients with syndromic and complex craniosynostosis have various physical and mental problems. More insight on these problems, per syndrome, could provide guidance to improve patient treatment and follow-up. Methods A cross-sectional, comparative study on 131 patients and their parents was performed. Health-related quality of life was measured with the HUI-3 and the Visual Analogue Scale (VAS). All data were compared to a normative Dutch population. Vision, hearing and intelligence were objectively measured. Results The HUI-3 and the VAS were significant lower compared to the normative Dutch population. All syndromes have a high prevalence of vision and speech problems. Cognitive problems were mainly reported in patients with Apert, Crouzon and Muenke syndrome. Ambulation and dexterity problems were seen in Apert, Crouzon, Saethre–Chotzen and complex craniosynostosis. Only patients with Apert syndrome scored significantly worse on pain. The HUI-3 had a medium to strong correlation with the objectively measured outcomes. Conclusions The overall quality of life is lower in patients with syndromic and complex craniosynostosis. To improve quality of life, more attention is needed for problems with vision and speech.

Purpose The value of intraoperative neurophysiological monitoring (IONM) with surgical detethering in dysraphic patients has been questioned. A retrospective analysis of our series of 65 patients is presented with special focus on technical set-up and outcome. Methods All patients were diagnosed with a tethered cord (TC) due to spinal dysraphism. A high-risk group (HRG) was determined consisting of 40 patients with a lipomyelomeningocele and/or a split cord malformation sometimes in combination with a tight filum terminale. The surgical procedure was a detethering operation in all cases performed by a single surgeon during a 9-year period (1999–2008). A standard set-up of IONM was used in all patients consisting of motor-evoked potentials (MEP) evoked by transcranial electrical stimulation (TES) and electrical nerve root stimulation. In young patients, conditioning stimulation was applied in order to improve absent or weak MEPs. Results IONM responses could be obtained in all patients. Postoperative deterioration of symptoms was found in two patients of whom one patient belonged to the HRG. Mean maximal follow-up of all 65 patients was 4.6 years (median 4.1 years). Long-term deterioration of symptoms was found in 6 of 65 patients with a mean follow-up of 5 years (median 5.3 years). Conclusion The use of IONM is feasible in all TC patients. The identification of functional nervous structures and continuous guarding of the integrity of sacral motor roots by IONM may contribute to the safety of surgical detethering.

Introduction Medulloblastoma is the most frequent type of embryonal tumor in the pediatric population, accounting for 20–25% of all brain tumors in children. Recently, the suspected contribution of the Polycomb group (PcG) genes in medulloblastoma development was described. PcG genes play an important role in developmental processes; they are also involved in the self-renewal of hematopoietic and neural stem cells as well as in malignant transformation. Purpose In this study, we evaluated the expression of BMI1and PCGF2, members of family of PcG genes, and their potential target, MYC oncogene, and analyzed their association with demographic and clinical data. Materials and methods Thirty-one children (18 males and 13 females, aged from 0.4 to 17 years) with medulloblastoma were included in this study. The gene’s expression level was measured by quantitative real-time PCR, obtained using the two-color multiplexing technique. Results We found that the higher expression levels of BMI1 and PCGF2 genes were associated with significantly decreased patient survival (p = 0.02 and p = 0.012, respectively). Significant differences between gender were found, with a higher expression level of the PCGF2 gene observed among females (p = 0.02). Conclusion Our analysis showed correlation between BMI1 and PCGF2 gene’s expression and survival in children with medulloblastoma.

Purpose Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals. Methods This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5–T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75–12) years were followed up clinically for more than 2 years. Results The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p

Objective It is well known that 10–15% of hydrocephalus cases at childhood and 40–50% in premature infants, occur following Germinal matrix hemorrhage (GMH). Such hemorrhages are reported to arise due to the rupture of germinal matrix (GM) vessels as a result of cerebral blod flow changes among infants with

Objects Our objective was to develop an oligonucleotide DNA microarray (OMA) for genome-wide microRNA profiling and use this method to find miRNAs, which control organic development especially for nervous system. Materials and methods Eighteen organic samples included cerebrum and spinal cord samples from two aborted human fetuses. One was 12 gestational weeks old (G12w) and the other was 24 gestational weeks old (G24w). Global miRNA expression patterns of different organs were investigated using OMA and Northern blot. Conclusion The OMA revealed that 72–83% of miRNAs were expressed in human fetal organs. A series of microRNAs were found specifically and higher-expressed in the human fetal nervous system and confirmed consistently by Northern blot, which may play a critical role in nervous system development.

There has been an increasing interest in articles reporting on clinical prediction models in pediatric neurosurgery. Clinical prediction models are mathematical equations that combine patient-related risk factors for the estimation of an individual’s risk of an outcome. If used sensibly, these evidence-based tools may help pediatric neurosurgeons in medical decision-making processes. Furthermore, they may help to communicate anticipated future events of diseases to children and their parents and facilitate shared decision-making accordingly. A basic understanding of this methodology is incumbent when developing or applying a prediction model. This paper addresses this methodology tailored to pediatric neurosurgery. For illustration, we use original pediatric data from our institution to illustrate this methodology with a case study. The developed model is however not externally validated, and clinical impact has not been assessed; therefore, the model cannot be recommended for clinical use in its current form.

Premature closure of the metopic suture results in a growth restriction of the frontal bones, which leads to a skull malformation known as trigonocephaly. Over the course of recent decades, its incidence has been rising, currently making it the second most common type of craniosynostosis. Treatment consists of a cranioplasty, usually preformed before the age of 1 year. Metopic synostosis is linked with an increased level of neurodevelopmental delays. Theories on the etiology of these delays range from a reduced volume of the anterior cranial fossa to intrinsic malformations of the brain. This paper aims to provide an overview of this entity by giving an update on the epidemiology, etiology, evolution of treatment, follow-up, and neurodevelopment of metopic synostosis.