Search

Introduction: Cranial deformities have always existed, but it is only until recently that they provoked a greater interest. Several reports have demonstrated an increasing tendency for occipital plagiocephaly. This work presents an analysis of the clinical-epidemiological features of these deformities in our area., Patients and Methods: The medical records and neuroimaging studies of 158 children seen at our hospital due to a skull deformation were analyzed, paying special attention to risk factors., Results: During the study period, an increase in the number of consultations for skull deformation of children was noted. The mean age for the patients at consultation was 9 months. There was a predominance of boys (68%) over girls. The deformities were: unilateral- (89.2%) or bilateral-posterior plagiocephaly (7.6%), and dolicochephaly (3.2%). In addition to the supine position for sleeping, there were several risk factors, among them pericerebral collections of cerebrospinal fluid found in 50% of children subjected to neuroimaging studies. Most children were managed conservatively, while 12 patients were given helmets, which led to an improvement in 136 cases., Discussion and Conclusions: The present findings agree with those in the current literature. A unique result of this study was the high rate of pericerebral fluid collections found in children assessed with neuroimaging methods. The increase in positional plagiocephaly seems to parallel the application of the recommendations for supine sleeping position established by the American Academy of Pediatrics for preventing the sudden infant death syndrome. The role played by Pediatricians in the detection, initial management and referral of these children is highlighted. Prevention measures seem to be more important than those regarding treatment., (Copyright © 2011 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.)

The role of radiosurgery after multimodality treatment of recurrent desmoplastic adult medulloblastoma is analyzed. The ultra-early clinical and pathological response of this tumor to adjunctive radiosurgery is stressed.

Introduction: The presence of a dermal sinus on a child's back is a common cause for paediatric neurosurgical consultation. The relative frequency of these lesions and fears on their possible clinical consequences enhances the importance of early diagnosis and treatment. With this work we aimed to search for the most relevant clinical features that might indicate an intradural penetration of the lesions and that may advise performing neuroimaging studies and a paediatric neurosurgical consultation., Patients and Methods: The records pertaining to children diagnosed with sacro-coccygeal pits seen at our institution during the years 2005-2009 were reviewed. A Pub Med search of the most relevant articles on the subject was also performed., Results: Thirty-two children diagnosed with sacro-coccygeal pits were seen at our institution in the study period. Most cases had been sent for neurosurgical consultation by their paediatricians, paediatric surgeons or paediatricians of the emergency services in our region. Seventeen patients were submitted to some neuroimaging study and 15 were evaluated only by physical examination. In no patient was an intradural penetration of the lesion observed. The lack of reports on coccygeal sinuses probably reflects the unimportance given to these lesions in the absence of neurological involvement., Conclusions: A detailed physical examination can reduce the number of neuroimaging studies, an intergluteal localization of the sinus being the most important diagnostic clue. Doubtful cases of an intradural penetration of the lesion can be further evaluated by ultrasound as a preliminary screening tool and by magnetic resonance and neurosurgical consultation if deemed necessary., (Copyright © 2010 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.)

We report the case of a 13-year-old girl with an increased hypophysis that mimicked an adenoma, who developed a partial empty sella on MRI after an acute episode of hydrocephalus. After replacement of a CSF shunt, the intracranial pressure returned to normal and the hypophysis filled up again all the sellar fossa. We discuss the possibility of the involvement by an ischemic atrophy of the adenohypophysis in the development of a primary empty sella with idiopathic chronic raised intracranial pressure that prevents the recovery of the gland volume after restoring the intracranial pressure to normal values. Restitution of empty sella may be an indicator of normal intracranial pressure in these cases.

Radionecrosis with brain edema is a complication of radiosurgery. Three female patients harbouring a frontal pole, petrous and parasagital parietoocipital meningiomas respectively who had been treated with LINAC radiosurgery are presented. Those patients developed, between two and eight months later, a severe symptomatic radionecrosis with a huge brain edema resistant to the usual steroid therapy. Only after 40 sessions of hyperbaric oxygen, a good remission of the lesions was obtained. There are few cases reported in the literature with such a good outcome. Consequentely, this therapy must be taken into account to treat this type of radiosurgical complication before considering surgery.

Objectives: With this 1-year retrospective study we aimed to analyze our experience on the utilization of real-time bidimensional (2-D) ultrasonography as an aid for the localization of deep-seated supratentorial brain tumours., Material and Methods: During the year 2006 we performed 2-D ultrasonographic localization studies in patients undergoing excision of subcortical supratentorial brain tumours whose nature was pathologically proven. The ultrasound machines utilized were 2410 A ultrasounds HP and Phillips HDI 3500 ATL. To check gross anatomical structures we used a 3 MHz probe and then a 5 MHz sound to define the brain tumour characteristics. Coronal and sagittal cuts were obtained during parietal or temporal craniotomies, and axial and sagittal slices in the case of frontal masses. After brain tumour removal and after a thorough irrigation with saline, new image acquisitions were performed to confirm the completeness of tumour excision. The amount of removed tumour was also verified by a post-contrast computerized tomography (CT) scan performed after the surgery., Results: The study group was composed by 30 patients with ages comprised between 28 and 82 years. The time required for tumour localization was 17.5 (+/- 1.9) min. The lesions were approached though 8 temporal, 7 parieto-occipital, 8 parietal, 2 fronto-parietal and 5 temporo-parietal craniotomies. Mean depth of the lesions was 5.3 (+/- 1.6) cm. The histopathologic diagnosis was 17 high-grade gliomas, 3 low-grade astrocytomas, 8 metastatic lesions and 2 oligo-astrocytomas. High-grade gliomas were more echogenic than low-grade tumours and than oedema. No residual tumour was detected at the end of the surgery except in two cases in which a tumoral rest was left due to the proximity of the lesion to eloquent cerebral areas. Postoperative CT scans confirmed the completeness of tumour removal in the patients of the study as assessed by intraoperative ultrasounds., Conclusions: Real-time 2-D ultrasonography affords an adequate image quality for performing guided-craniotomy in supratentorial brain tumours, as it allows for a safe and accurate localization of the lesions. Its use is mainly indicated in the removal of tumours located in, or close to, important anatomical and functional brain areas and to depict the presence of tumour rests after surgical removal of cerebral neoplasms.

Background and Objective: The aim of this study was to evaluate epidemiological and clinical aspects of brain abscess (BA) and changes in clinical patterns during the last 30 years., Patients and Method: Observational study of a cohort of non-pediatric patients with BA admitted at a 944-bed hospital. Data collection from clinical records was done according to a standard protocol. We analysed epidemiological, clinical and microbiological data and localization as well as changes during a 30 year period divided in 2 equal length phases: 1976-1989 (P1), and 1990-2005 (P2)., Results: 108 patients with BA were included (mean age: 45 years; range: 12-86; > 40 years in 42.4% P1, and 71.4% in P2, p < 0.05); 66 patients were treated in P1 and 42 in P2 (annual incidence: 4-5 cases and 2-3 cases per 10(6) population in P1 and P2, respectively). A predisposing condition was identified in 86% cases with statistically significant differences (p < 0.05) in: otitis media (18.2% vs 2.4%); dental infection (3% vs 16.7%); penetrating cranial trauma (16.7% vs 0%); post-neurosurgery (15.1% vs 21.4%), in P1 and P2, respectively; microbiologic diagnosis was made in 76% (no statistical differences P1/P2). Clinical aspects statistically different in P1/P2: severely altered mental status (10.6% vs 0%); vomiting (37.9% vs 21.4%); focal neurological deficits (37.9% vs 71.4%). No statistically significant differences were found in other epidemiological, clinical, radiological, microbiological or outcome characteristics in P1/P2., Conclusions: In spite of a lower incidence in P2 and certain epidemiological and clinical differences in P1/P2, mortality and relapses rates have not significantly changed in a 30 year period.

Introduction: Neurocysticercosis is the most frequent parasitic disease affecting the central nervous system. It is a disease that is endemic to certain countries in South America. The phenomenon of immigration, however, has increased its prevalence in developed regions due to the arrival of immigrants from endemic areas., Aim: To present the clinical and demographic characteristics of the cases of neurocysticercosis attended in a tertiary care hospital in the city of Murcia., Patients and Methods: We conducted a descriptive, retrospective study by reviewing the medical records of patients with a hospital diagnosis of neurocysticercosis over a nine-year period (1997-2005). Demographic and clinical data on these patients were collected., Results: Twenty-three patients (three under 12 years of age) were found. Mean age: 29.6 years. Countries of origin: Ecuador and Bolivia. The most frequently observed clinical manifestations were: epileptic seizures (73.9%), headache (39.1%) and neurological focus (26.1%). Albendazole was employed in 91.3% of cases and corticoids in 73.9%. The most frequently used drug in patients who received antiepileptic therapy was phenytoin. Four patients required surgical treatment. During the follow-up period, 52.8% of the patients were asymptomatic., Conclusions: Neurocysticercosis is a disease that is becoming increasingly more prevalent in Spain and we should suspect its presence in patients from endemic areas who visit because of clinical symptoms involving the central nervous system.

Background: Spinal cord rethetering can occur after the primary surgical repair of myelomeningoceles (MMC) and lipomeningoceles (LMC) and produce devastating physical and psychological consequences. The inadvertent introduction of skin elements at the time of the initial surgery can lead to the growth of intraspinal epidermoid or dermoid cysts., Objectives: To review the incidence of spinal cord tethering following surgery for open and occult spinal dysraphism and to analyze factors that might influence the appearance of this complication. We also aimed to search technical measures at the time of the primary operation that might prevent the occurrence of symptomatic cord retethering., Material and Methods: We reviewed the medical records of patients submitted to surgical repair of MMC (n=162) or occult spinal dysraphism (n= 54) during the period 1975-2005 who developed symptomatic tethered cord syndrome., Results: Eleven of 162 (6.79%) patients with MMC and 2 of 54 (3.7%) with LMC developed clinical symptoms and signs of spinal cord tethering after intervals ranging from 2 to 37 years after the initial surgical repair of their back lesions. Indications for surgical re-exploration were based mainly on clinical grounds. Postoperative fibrosis was a constant finding in all instances. Other surgical findings included inclusion tumors of cutaneous origin (n=3), lumbar canal stenosis (n= 2), foreign body reactions (n= 2), residual lipoma (n= 1), and a tight hyalinized filum (n=1). Interestingly, 3 of 162 (or 1.85%) myelomeningoceles were found to harbor an intradural epidermoid tumor at the time of spinal cord dethetering, accounting for an incidence of cutaneous inclusion tumors of 27% in cases of post- MMC repair tethering. After a mean follow-up time of 5.5 years, eight patients were improved, two were unchanged and one was worsened., Conclusions: Neurological deterioration is not a necessary consequence of the natural history of patients with MMC or LMC. Early or late clinical deterioration can be due to spinal cord re-tethering and deserves timely investigation and surgical exploration. Results of surgical intervention were rewarding as 92% of the patients showed improvement or stabilization in their otherwise deteriorating condition. We also report two infrequent causes of spinal cord deterioration: lumbar canal stenosis and intense foreign-body reactions to implanted materials.

Objectives: To assess the incidence and characteristics of postoperative changes in the higher cerebral functions after elective intracranial surgery under general anesthesia., Patients and Methods: This is a prospective study of 60 patients, aged 18-81 years, submitted to neurosurgical operations, allocated into two groups of 30 patients each: intracranial surgery group, patients submitted to craniotomy, and extracranial surgery group or control group, patients submitted to spinal procedures. All patients were given the Abbreviated Mental Test (AMT) on the day before to the operation, and then 2 and 24 hours after the end of the procedure. All individuals were managed with the same anesthetic technique., Results: No differences in regard to demographics, duration of the operation, ASA physical state, and habits were found between the two groups. No differences in the pre-surgical and post-surgical AMT mean score were encountered between patients submitted to intracranial 9.87 +/- 0.35 or to spinal surgeries 9.80 +/- 0.41. Similarly, there were no significant differences between the two groups in the results of the AMT performed at 2 and 24 hours after the end of the surgeries. Only two subjects undergoing spinal procedures had a score of < or = 8 in the AMT performed 2-hours after the operation, while none showed a decrease in the 24-hour test score., Conclusions: Patients submitted to intracranial surgery did not show any changes in cognitive or attention functions during the first postoperative 24 hours as assessed by the AMT.

Overdrainage in ventricular shunting constitutes a difficult to prevent and to treat complication. The authors reviewed a retrospective series of 512 children submitted to a ventricular shunting procedure aimed at analysing factors influencing this type of complication. The causes for the hydrocephalus were congenital (n=172), post-myelomeningocele (n=123), posthemorrhagic (n=103), tumoral (n=64), postmeningitis (n=40) and posttraumatic (n=10). Eighty-eight children (17.8%) evolved with a complication related to the excessive function of the valve. The authors investigated the relationship between hydrocephalus' etiology and type of overdrainage syndromes. The most frequent complication was ventricular catheter block (n=50), followed by symptomatic slit ventricle syndrome (SVS) (n=19), subdural hematoma (n=10) and trapped fourth ventricle (n=9). There were no statistical differences regarding complications for each etiologic subset of hydrocephalus. SVS occurred in 19 children (3.71%), a low rate according to the current literature. Posthemorrhagic and postinfectious hydrocephalus grouped together showed a higher rate of SVS (p=0.005), a feature that we attributed to the cerebral destruction caused by these two conditions. Treatment of SVS was complex and required diverse procedures, applied in an escalated way, which included five decompressive craniectomies. The authors suggest avoiding, as much as possible, the use of ventricular shunts, and recommend the alternative use of new technology valves and neuroendoscopic procedures.

Tension pneumocephalus is a rare and severe complication appearing after posterior fossa procedures in the sitting position. This complication may endanger the patient's life and require immediate treatment. However, tension pneumocephalus after neurosurgical procedure in the supine position have been scarcely reported. We report such a complication occurring in a 14-year-old girl submitted to a frontotemporal craniotomy for removal of an astrocytome performed with the patient supine. We discuss ethiopathogenesis and management of this complication.

Objective: To determine the behavior of the copper-zinc superoxide dismutase enzyme (SOD/Cu/Zn) in tissue homogenates of rat brains with ischemic lesions produced following the model of global cerebral ischemia without arterial hypotension., Material and Methods: Thirty rats were randomly assigned to five groups of six animals each. Bilateral carotid occlusion was temporarily produced in 24 rats (4 groups) during periods of 5, 15, 30 and 60 minutes, respectively. All the animals were then submitted to reperfusion for 30 minutes and after that, they were sacrificed. A control group of 6 rats was not exposed to arterial occlusion. Cerebral homogenates of the rats' brain were obtained and submitted to spectrophotometer analysis., Result: The control group showed the lowest mean values in SOD/Cu/Zn activity (40.60+/-11.42 U/mg of protein), while the highest mean values (60.34+/- 13.52 U/mg of protein) corresponded to the rats submitted to ischemia for 60 minutes, what indicates a statistically significant difference (p = 0.016) between the two groups., Conclusions: SOD/Cu/Zn activity in rats increases during the production of ischemic cerebral lesions. The analysis of SOD/Cu/Zn activity showed an important tendency to rise from the 30 minutes period of ischemic lesion and reached statistically significant values at 60 minutes from the beginning of the ischemic injury. The experimental model of global brain ischemia without arterial hypotension used in this study constitutes a reliable method for researching cerebral ischemia.

Introduction: Ventriculoatrial and ventriculopleural shunts (VPS) are alternatives to ventriculoperitoneal shunts for draining cerebrospinal fluid from patients with hydrocephalus. VPS has seldom been used because of the risk of respiratory insufficiency due to pneumothorax or pleural effusion. However, valves are currently available with anti-siphon devices for use with standard shunting systems to prevent the development of pleural effusion. The aim of this study was to analyze outcome after VPS in eight patients in whom we used the new valves for avoiding overdrainage of cerebrospinal fluid., Material and Method: Nine VPS procedures were performed in eight hydrocephalic patients between 1988 and 2000. We used differential pressure valves in eight procedures and a flow regulator valve in one. The externally adjustable Sophy valve was used in six cases. The indication for VPS was peritoneal adhesions in four cases, persistent ascites in two, ventriculoatrial valve obstruction in one, and infection of the peritoneal shunt (peritonitis) in one. The ninth case involved replacement of a previously obstructed valve., Results: After a follow-up period of 22 months all shunts were functioning well and the only patient with symptoms of hydrocephalus was the one who required valve replacement at six months. No surgical morbidity or mortality was observed, and only one patient developed transitory signs of excessive cerebrospinal fluid drainage, which was corrected by regulating the magnetic valve gradient. The death of one patient 36 months after surgery was unrelated to pleural drainage., Conclusions: Valves newly designed to prevent overdrainage of cerebrospinal fluid give satisfactory results, such that VPS should be considered as an alternative to peritoneal drainage.

Latex allergy has become a health problem of growing interest due to the severe clinical manifestations it may produce. Previous reports indicate a prevalence of latex allergy in patients with spina bifida (SB) ranging between 10% and 73%. From the initial surgical repair of the myelomeningocele, children with SB are submitted to multiple surgeries due to the neurologic, orthopedic and urologic problems they may present. Consequently, these children are exposed to several latex-containing products during their multiple interventions. Several reports indicate that latex allergy in SB children is related to age, and especially to the number of operations that they are given, and perhaps to an unknown genetic predisposition. Accordingly, latex allergy manifestations can be prevented. In this connection, we have elaborated at our hospital protocols for the management of the three clinical situations in which these patients can present. These measures include: (1) To avoid using latex-containing products since the birth of children with SB. (2) In children already operated of myelomeningocele but without evidence of latex allergy, to prevent the use of latex materials during their successive admissions to hospital and during further surgeries. And (3) In children known to have developed latex allergy, to dispose of especial nursing measures and of a latex-free operating room. The preventive measures that have been started at our Hospital are easy to carry out, do not suppose a high economic cost, and are not uncomfortable for the hospital's staff.

Pneumocephalus occurs commonly soon after intracranial surgery. When it presents as a significant increase in intracranial pressure it is called pressure pneumocephalus, a severe, life-threatening complication of neurosurgery that requires immediate treatment. Tension pneumocephalus must be suspected in patients unexpectedly fail to awaken at the end of surgery or who present progressive neurological deterioration after posterior fossa surgery. Diagnosis is by computerized axial thomography of the brain. Treatment is simple, consisting of promptly releasing the pressurized gas by trephination to save the patient's life or prevent severe neurological sequelae. We report two cases of pressure pneumocephalus that illustrate several risk factors: sitting position during surgery, preoperative hydrocephaly, surgical opening of the fourth ventricular and the presence of cerebrospinal shunt during surgery.

Objectives: To determine whether the direct application of a single dose of methadone on the dura mater at the end of surgery to repair a lumbar disk hernia provides effective analgesia over the next 24 hours., Patients and Methods: We conducted a randomized double blind study in 40 ASA I patients undergoing elective herniated disk repair under general anesthesia. The sample was divided into two groups (A and B). Group A patients received a solution of methadone in saline solution (5 mg methadone/5 ml saline) applied to the dura before the end of surgery. Group B patients (controls) received only 5 ml of saline. Pain intensity was assessed on a visual analog scale (VAS) during the postoperative period. Also recorded were the observer's impression and the amount of analgesia (ketorolac) consumed through a system providing patient controlled analgesia., Results: Each group contained 20 patients. Group A patients needed significantly less postoperative analgesia (64.2 +/- 14.3 mg) than group B patients (109.6 +/- 16.5 mg). The VAS scores were significantly lower in group A during the first two hours after surgery and were correlated with the observer's impression. No patients suffered serious complications during the study., Conclusions: Topical administration of 5 mg of methadone on the dura mater at the end of herniated lumbar disk repair is an easy, safe and effective technique for providing postoperative analgesia.