Long-term control of hydrocephalus via endoscopic third ventriculostomy in children with tectal plate gliomas.

OBJECTIVE: We report the control of hydrocephalus in children with presumed tectal plate gliomas by the use of endoscopic third ventriculostomy (ETV). METHODS: The hospital records, office charts, and imaging studies from children who underwent ETV at the Children's Hospital of Alabama were reviewed. Thirteen children with the diagnosis of tectal plate glioma and hydrocephalus were identified. ETV was the primary therapy instituted for all but one of these children. Successful treatment outcome was defined as shunt freedom, improvement in symptoms, and reduced ventricular size. RESULTS: Thirteen children underwent a total of 15 ETVs, and all children were shunt-free at their most recent follow-up examinations. One child underwent successful secondary ETV, one child underwent shunt removal concomitant with the initial ETV, and one child underwent shunt removal concomitant with secondary ETV. Symptoms and signs resolved in all patients. All postoperative cranial imaging studies revealed normal or reduced ventricular size as compared with preoperative cranial imaging scans. The median follow-up period was 31 months. CONCLUSION: In our surgical experience, ETV has been uniformly successful in the management of hydrocephalus caused by tectal plate gliomas in children. ETV should be considered the treatment of choice for hydrocephalus in pediatric patients with tectal plate gliomas.

Efficacy of scheduled nonnarcotic analgesic medications in children after suboccipital craniectomy.

OBJECT: The authors performed a study to evaluate the efficacy of a regimen of scheduled minor analgesic medications in managing postoperative pain in children undergoing intracranial procedures. METHODS: Postoperative pain scores were analyzed in two groups of children who underwent decompressive surgery for Chiari malformation: Group A underwent a scheduled regimen of minor oral analgesic medications (standing doses of acetaminophen [10 mg/kg] and ibuprofen [10 mg/kg] alternating every 2 hours) and Group B received analgesic medication when requested. Fifty children underwent a standard occipital craniectomy (25 in each group). The pain scores were significantly lower in Group A during most of the postoperative period. Length of stay (LOS) was shorter (2.2 compared with 2.8 days), and narcotic and antiemetic requirements were also lower in Group A patients than in Group B patients. Patients with spinal cord syringes exhibited a similar postoperative status to those without, and similar improvements in pain scores with scheduled minor analgesic medications were also evident. CONCLUSIONS: A regimen of minor analgesic therapy, given in alternating doses every 2 hours immediately after craniotomy and throughout hospitalization, significantly reduced postoperative pain scores and LOS in children in whom suboccipital craniotomy was performed. Narcotic and antiemetic requirements were also decreased in association with this regimen. Application of this postoperative analgesia protocol may benefit children and adults in whom various similar neurosurgical procedures are required.

Complications of ventriculosubgaleal shunts in infants and children.

INTRODUCTION: The ventriculosubgaleal shunt has been used for the temporary bypass of the normal cerebrospinal fluid (CSF) pathways. To date, a large series of complications from this procedure has not been elaborated upon in the literature. PATIENTS AND METHODS: We retrospectively reviewed all such shunts (170) placed at our institution over the last 6 years and documented all complications from this procedure. The majority of patients operated upon were premature infants with intraventricular hemorrhage and subsequent hydrocephalus. This technique was used in a much smaller group of patients in whom the peritoneal cavities were not currently candidates for distal shunt implantation but would have been with time. Other patients in whom this technique was used were those with malignant brain tumors, intraventricular abscesses, chronic truncal wounds, chronic subdural hygromas, and meningitis. RESULTS: Complications from subgaleal shunting included infection (5.9%), intracranial hemorrhage (1.1%), and wound leakage (4.7%). CONCLUSIONS: We believe the benefits afforded by ventriculosubgaleal shunting significantly outweigh the risks of the procedure and greatly ease the burden of care for this select population of children. Based on the literature and our own experience, the complications from this procedure are not excessive or extraordinarily unique compared with other neurosurgical CSF diversion techniques.

Polymerase chain reaction for the rapid detection of cerebrospinal fluid shunt or ventriculostomy infections.

OBJECTIVE: Infection after cerebrospinal fluid (CSF) shunts or ventriculostomies is a common complication associated with significant morbidity and mortality. Polymerase chain reaction (PCR) is a powerful molecular technique that allows rapid and precise amplification of bacterial deoxyribonucleic acid (DNA) and has proven a powerful tool in the detection of a wide variety of clinically important infectious diseases. We analyzed specimens of CSF derived from ventriculoperitoneal shunts or external ventricular drains by using both conventional cultures and PCR and report herein our preliminary results. METHODS: We selected 86 CSF samples from adult patients who underwent either shunt tap or routine surveillance cultures of their ventriculostomy. These specimens were chosen from a larger group of 300 specimens that were routinely collected (many serially) in our clinical practice. They were chosen because clinical suspicion of infection was increased because of either patient signs and symptoms (fever, stiff neck, lethargy, worsening neurological examination) or preliminary laboratory analysis of CSF data (increased white blood cell count, increased protein level, decreased glucose). We considered this subgroup optimal to efficiently initiate our investigation of the correlation of PCR and culture results. CSF was increased by using standard culture techniques and by using PCR. Samples of CSF that were to undergo PCR had DNA extracted, purified, and amplified for 16S rRNA using primers 16S-Forward and 16S-Reverse of conserved sequence regions of all bacteria. DNA was PCR-amplified for 30 cycles. One microliter of the first PCR product was subjected to nested PCR using primers specific for gram-positive and gram-negative bacteria. Samples were also subjected to PCR amplification for specific detection of Propionibacterium acnes, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus using specific primers for 16S rRNA Propionibacterium, nuclease gene of Staphylococcus, and Mec gene of methicillin-resistant Staphylococcus aureus. RESULTS: For 18 of 86 specimens (21%), both the culture and PCR were positive. For 30 of 86 specimens (35%), both the PCR and culture results were negative. For 42 of 86 specimens (49%), cultures were negative and PCR was positive. There were no positive culture results with negative PCR results. Most negative culture/positive PCR cases occurred after prolonged intravenous antibiotics. Of the 56 PCR-positive specimens, 30 were positive for Propionibacterium acnes, whereas 40 were positive for Staphylococcus aureus. Of the Staphylococcus aureus-positive specimens, two were positive for methicillin resistant-Staphylococcus aureus. Among the 56 PCR-positive specimens, 30 were positive for both Propionibacterium acnes and Staphylococcus aureus; gram-negative organisms were not detected by any method in these specimens. CONCLUSION: These preliminary data suggest that PCR is a highly sensitive, rapid, and potentially promising modality for the detection and treatment of CSF shunt ventriculostomy infection.

Cervical spine involvement in Larsen's syndrome: a case illustration.

We present the progressive clinical course of a child with myelopathy attributable to cervical spine abnormalities associated with Larsen's syndrome. After anterior and posterior cervical fusion, his preoperative symptoms of weakness, gait dysfunction, and hyperreflexia have improved at 9-month follow-up. The progressive course and importance of early referral and intervention should be of interest to the general pediatric community.