Predictive Factors for the Occurrence of Perioperative Complications in Pediatric Posterior Fossa Tumors.

OBJECTIVE: Central nervous system tumors are the most common solid neoplasm in children, 60%-70% occurring in the posterior fossa. Surgery is the mainstay of treatment but surgery in the pediatric population is associated with a high risk of perioperative complications. We aimed at analyzing the perioperative complications after posterior fossa surgery in a pediatric population and identifying the associated risk factors. METHODS: Retrospective study of all pediatric patients undergoing surgery for resection of a posterior fossa tumor between 1999 and 2019, at the University Hospital of Lausanne. Data were collected including age, clinical presentation, tumor localization, presence of preoperative hydrocephalus, timing of surgery, surgical approach, surgical team, extent of surgical resection, perisurgical complications, and histopathological diagnosis. Statistical analysis was performed to correlate the data with the risk of complications. RESULTS: Sixty-seven patients were included. Perisurgical complications were identified in 39 patients (58.2%), of which 14 (35.9%) required corrective interventions. The perioperative mortality rate was zero. In the univariate analysis, surgery performed under emergency conditions, transvermian and telovelar approaches were statistically correlated with an increased rate of complications. Extent of resection, hydrocephalus, and Lansky index at presentation were not predictive of perioperative complications. Midline tumor, tumor volume >25 cm3, and surgery performed by a nonspecialized pediatric onconeurosurgeon were found to be independent risk factors in the multivariate analysis. CONCLUSIONS: Surgery in the posterior fossa in the pediatric population harbors a high risk of complications. Identifying the variables contributing to these complications is important in order to improve surgical management of these patients.

Interhemispheric Approach.

The interhemispheric approach is the natural route to reach the parafalcine and paraventricular structures through the interhemispheric fissure. In this chapter, we report the main anterior and posterior corridors of the interhemispheric approach.

Three-Dimensional Volumetric Assessment of Resected Gliomas Assisted by Horos Imaging Software: Video Case Series of Postoperative Tumor Analyses.

Horos (LGPL 3.0; GNU Lesser General Public License, Version 3) is a free, open-source medical image viewer with a user-friendly interface and three-dimensional (3D) volumetric rendering capabilities. We present the use of Horos software as a postoperative tool for residual tumor volume analysis in children with high-grade gliomas (HGG). This is a case series of two pediatric patients with histologically confirmed high-grade gliomas who underwent tumor resection as definitive treatment from June 2011 to June 2019. Volumetric data and extent of resection were obtained via region of interest-based 3D analysis using Horos image-processing software. Horos software provides increased accuracy and confidence in determining the postoperative volume and is useful in assessing the impact of residual volume on outcomes in patients with high-grade gliomas. Horos software is a highly effective means of volumetric analysis for the postoperative analysis of residual volume after maximal safe resection of high-grade gliomas in pediatric patients.

Early Decompressive Craniectomy as Management for Severe Traumatic Brain Injury in the Pediatric Population: A Comprehensive Literature Review.

BACKGROUND: Severe traumatic brain injuries (TBIs) are a principal cause of neurologic dysfunction and death in the pediatric population. After medical management, the second-tier treatment is decompressive craniectomy in cases of intractable intracranial pressure (ICP) elevation. This literature review offers evidence of early (within 24 hours) and ultraearly (6-12 hours) decompressive craniectomy as an effective form of management for severe TBI in the pediatric population. METHODS: We conducted a literature review of articles published from 1996 to 2019 to elucidate neurologic outcomes after early decompressive craniectomy in pediatric patients who suffered a severe TBI. Time to decompressive craniectomy and neurologic outcomes were recorded and reported descriptively. Qualitative data describe clinically important correlations between pre- and postoperative ICP levels and improved postoperative neurologic outcomes. RESULTS: Seventy-eight patients were included in this study. The median age of patients at diagnosis was 10 years of age (range, 1 months to 19 years). Median admission Glasgow Coma Scale score was 5 (range, 3-8). Time to decompressive craniectomy ranged from 1 to 24 hours. Median peak preoperative ICP was 40 (range, 3-90; n = 49). Median postoperative ICP was 20 (range, 0-80; n = 33). Median Glasgow Outcome Scale (GOS) score at discharge was 2 (range, 1-5; n = 11). Median GOS score at 3- and 6-month follow-up was 3 (range, 1-5; n = 11). Median GOS score at 7- to 23-month follow-up was 4 (range, 1-5; n = 29). Median GOS score at 24- to 83-month follow-up was 4 (range, 1-5; n = 31). Median modified Rankin Scale score at discharge was 3 (range, 2-4; n = 6). Median modified Rankin Scale score at 6- to 48-month follow-up was 2 (range, 0-3; n = 6). Median Rancho Los Amigos Scale (RLAS) score at discharge was 6 (range, 4-8; n = 5). Median RLAS score at 6-month follow-up was 10 (range, 8-10; n = 5). CONCLUSIONS: Early (within 24 hours), with consideration of ultraearly (within 6-12 hours), decompressive craniectomy for severe TBI should be offered to pediatric patients in settings with refractory ICP elevation. Reduction of ICP allows for prompt disruption of pathophysiologic cascades and improved neurologic outcomes.

Risk Factors for Dropping Out of Neurosurgical Residency Programs-A Survey Study.

BACKGROUND: Resident education has to adapt to a changing health care environment. Although aspects such as working hours and attrition rates have been studied in detail, data about the residents' perspective, especially in European countries, are underrepresented in the scientific literature. The aim of this study was to assess and report aspects of neurosurgical education in German-speaking countries and to identify risk factors for quitting or changing the neurosurgical residency program. METHODS: We conducted a nonanonymous online survey among neurosurgical residents in Germany, Austria, and Switzerland. Log-binomial regression models were calculated to further assess risk factors. RESULTS: Of 201 residents who responded to the survey, 37.3% (n = 75) dropped out of neurosurgical training programs, including 20 residents (10%) who ultimately quit neurosurgery and changed to another specialty. Only female gender (relative risk, 2.97; 95% confidence interval, 1.3-6.78) and starting residency in a city one studied or grew up in (2.38; 1.01-5.62) were significant risk factors. Residents who had close supervision at work (0.39; 0.17-0.89), who observed the residency program for >3 days before applying (0.54; 0.31-0.95), who had well-defined guidelines within the program (0.57; 0.35-0.92), and who were working in a university hospital (0.41; 0.26-0.64) were significantly less likely to quit or change their program. CONCLUSIONS: The high attrition rate, especially among female residents, in Germany, Austria, and Switzerland should encourage program directors to specifically address the issues reported by this survey during interviews and to further improve their residency program accordingly.

Contribution of bradykinin receptors to the development of secondary brain damage after experimental subarachnoid hemorrhage.

BACKGROUND: Subarachnoid hemorrhage (SAH) is the stroke subtype with the highest mortality and morbidity. Which molecular events mediate brain damage after SAH is not well understood. OBJECTIVE: To investigate the role of proinflammatory bradykinin B(1) and B(2) receptors for the pathophysiology of SAH. METHODS: B(1) and B(2) receptor knockout or wild-type mice were subjected to SAH by endovascular puncture. Intracranial pressure, regional cerebral blood flow, and mean arterial blood pressure were continuously monitored up to 60 minutes after SAH. Brain water content was quantified 24 hours after SAH; mortality, neurological function, and body weight were assessed daily for 7 days after hemorrhage. RESULTS: Intracranial pressure, regional cerebral blood flow, and mean arterial blood pressure did not differ between groups. Mortality was 60% in wild-type mice and 82% in B(1)R mice but only 20% in B(2)R animals (P < .05). B(2)R mice also exhibited less severe neurological deficits (P < .05), a less pronounced loss of body weight (P < .05), and significantly less brain edema formation (P < .05) compared with wild-type mice. CONCLUSION: Signaling mediated by bradykinin B(2) receptors contributes to mortality and secondary brain damage after SAH in mice. Thus, B(2) receptors may represent novel targets for the treatment of SAH.