Diagnostic delay of pediatric brain tumors in Israel: a retrospective risk factor analysis.

PURPOSE: Pediatric brain tumors (PBTs) are the most common solid tumors and the leading cause of cancer-related morbidity and mortality in childhood. Previous studies have shown a significant delay between the onset of symptoms and the diagnosis of these tumors. Delayed diagnosis of PBTs may lead to acute situations and irreversible neurological damage. In this study, we looked for the incidence of delayed diagnosis of PBTs in Israel. We tried to find the reasons for these delays and the associated risk factors in order to provide a feedback to the system for improved education and earlier diagnosis. METHODS: We analyzed the charts of 330 consecutive children aged 0-18 years diagnosed with brain tumors, between the years 1996 and 2004. In the cases where delay in diagnosis was suspected, further information was collected from a family interview. RESULTS: The average "time to diagnosis" was 7.7 months (SD ± 16.7). Symptomatic deterioration from the first symptom until diagnosis was found in about 50% of the cases. Unacceptable delay in diagnosis was found in 27% of the children. The major reason for delay was "delay in indicated imaging." Symptoms that were found to be associated with delayed diagnosis were torticollis, ataxia, and motor dysfunction. Interestingly, the examination by specialists such as ophthalmologists or neurologists was also associated with delayed diagnosis. CONCLUSIONS: There is an unacceptable rate of delay in the diagnostic process of PBTs in Israel. Greater awareness and familiarity with signs and symptoms associated with these tumors and lowering imaging threshold might minimize this phenomenon.

Interpeduncular arachnoid cysts in infants and children: insight into the entity based on a case series with long-term follow-up.

OBJECTIVE: Arachnoid cysts occupying the suprasellar region comprise 10-15% of intracranial distribution. Unlike large suprasellar cysts, pure interpeduncular cysts (IPCs) are rare, and their natural history is unknown. We describe a small series of children diagnosed with IPC and their long-term natural history. METHODS: A retrospective review was conducted of interpeduncular arachnoid cysts diagnosed over the years 2000-2010 at our center. Patients with clearly suprasellar cysts were excluded. Serial magnetic resonance imaging and long-term follow-up examinations were analyzed. Additionally, we conducted an extensive literature review focusing on the differences between suprasellar cysts and IPCs. RESULTS: We identified three pediatric patients with "pure" IPC; all of these had a follow-up of more than 5 years, and none was operated. Only six additional cases were identified in the literature. In both our experience and in the literature review, IPCs proved stable over the course of time, both radiologically as well as clinically. CONCLUSIONS: The clinical and radiological features of IPCs are not well defined. Variations in the relationship of arachnoid cysts in this area to Liliequist's membrane may explain the different subgroups that have been identified as well as the confusing nomenclature. IPCs are usually diagnosed as incidental findings or present with mild endocrine disorders. Associated findings of hydrocephalus, mass effect, and compression of neighboring structures, such as the chiasm, are not as frequent as with suprasellar cysts. Given the high likelihood of continuing stability, a conservative strategy of follow-up is recommended for pure IPCs that demonstrate preservation of the third ventricle.

Continuous spinal drain following endoscopic third ventriculostomy: a proposal to change the definition of failure.

PURPOSE: This study evaluates the safety, efficacy, and indications for continuous lumbar drainage (CLD) in patients following endoscopic third ventriculostomy (ETV). METHODS AND RESULTS: We retrospectively reviewed the clinical data of 22 consecutive patients treated between 1996 and 2010 with CLD after ETV. The decision to insert a CLD was made in selected patients only. CLD was inserted in cases of high measured intracranial pressure (12 patients), clinical symptoms indicative of continuing hydrocephalus (2 patients), and "prophylactically" in 8 patients, based either on the clinical condition of patients before ETV or on technical difficulties during the ETV procedure, which seemed to increase the risk of ETV failure. CLD insertion took place either in the operating room immediately following the ETV procedure or under very specific conditions and with close patient monitoring in an ICU setting. Only four patients eventually required shunting, all within 1 month after ETV. Therefore, the overall ETV success rate was 81.8% (18/22 patients). Of the 14 patients suffering from measured or clinically observed continuing hydrocephalus, 12 (85%) ultimately recovered without the need for a permanent shunt. Without the CLD, some of these patients would probably have been declared "failures" and referred for a standard shunt. CLD provided a time window following ETV for the absorption system to recover and return to full functionality. CONCLUSIONS: Selective usage of CLD is a reasonable and safe method to gain time and possibly facilitates the recovery of absorption capacity following ETV. CLD should be considered before conceding a post-ETV patient as a failure.

Placement of Ommaya reservoir following endoscopic third ventriculostomy in pediatric hydrocephalic patients: a critical reappraisal.

PURPOSE: Endoscopic third ventriculostomy (ETV) has become standard for obstructive hydrocephalus. Even a successful ETV can obstruct, leading to recurrence of symptoms and even death. A possible solution to this problem is leaving an Ommaya reservoir (OR) following the ETV. OR can be tapped in an emergency and for diagnostic purposes. No specific complications have been attributed to OR in this setting. We present our experience with OR in children undergoing ETV for hydrocephalus. MATERIALS AND METHODS: A retrospective study was conducted in hydrocephalic children that underwent ETV with OR insertion over 13 years (1997-2010) from a single institution. Data were collected from charts and follow-ups. RESULTS: Twelve patients (from 200 patients who had an ETV) underwent placement of OR with ETV. OR was reserved for a subgroup of patients in whom we anticipated complications-in children that presented with acute hydrocephalus and were in deteriorating condition, for pathologies believed to have a low predicted ETV success rate, or when the surgeon felt that the ETV procedure was suboptimal. OR was tapped in eight patients. Complications occurred in four patients: two cases of subdural effusion, one case of chronic subdural hematoma, and one CSF leak. Four ORs were removed due to complications, and four were converted to shunts. CONCLUSIONS: OR should be considered in selected patients undergoing ETV. Despite its obvious advantages, OR may be associated with a relatively high risk of extraaxial fluid collections. This association requires further investigation.

Modified bilateral subtemporal decompression for resistant slit ventricle syndrome.

PURPOSE: Slit ventricle syndrome (SVS) remains a major problem for early shunted children. Several conservative and surgical treatment paradigms have been suggested; however, there is no consensus on the optimal surgical treatment. We present our experience using bilateral subtemporal decompressions with dura and arachnoid opening for the treatment of a subgroup of children with severe and resistant SVS. METHODS: Fifteen children with severe and resistant SVS underwent a modified bilateral subtemporal craniectomy, with dura and arachnoid opening. Their clinical and radiological data were retrospectively reviewed. RESULTS: Seven (46.6%) patients had a complete recovery from their symptoms with a follow-up of 5.9 ± 2.6 years.The remaining eight (53.3%), underwent additional surgeries. Four (26.6%), had a single proximal shunt revision after dilatation of their ventricles. Following these procedures these four children are well and stable with a follow-up of 1.8 ± 2 years. The other four had further cranial vault expansion, one of which was followed by a proximal shunt revision. Thus, 11 of these 15 patients (73.4%) had a very good outcome, attributable to this technique, with a mean follow-up of 4.5 ± 3 years. CONCLUSIONS: Modified bilateral subtemporal decompression with dura and arachnoid opening yields a high cure rate for severe and resistant slit ventricle syndrome. Proximal shunt revision may be safely performed in a subset of patients that dilate their ventricles following the procedure. Further cranial expansion may be reserved for children with recurrent SVS symptoms who do not respond to STD and remain with very small ventricles.

Unusual case of 'trapped fourth ventricle' in a child with posthemorrhagic hydrocephalus--lessons learnt.

In most of the children with posthemorrhagic hydrocephalus (PHH), multidisciplinary follow-up is performed, with the focus on consequences of prematurity, cerebral palsy (CP) and hydrocephalus. A large fourth ventricle is common in these children but imaging performed in order to document ventricles and tissue damage is not oriented to exclude coexisting rare pathologies. We report a 3-year-old child with spastic CP, secondary to prematurity and PHH. A ventriculoperitoneal shunt was inserted at the age of 2 months. On follow-up imaging the child demonstrated well-drained supratentorial ventricles with a persistent large fourth ventricle. Because of a neurological change in spasticity and new-onset torticollis, a repeat MRI was performed, suggesting a cystic, nonenhancing lesion of the fourth ventricle. The surgical exploration revealed a large dermoid of the fourth ventricle. We analyze the differential diagnosis of a clinically significant large fourth ventricle in a shunted child with PHH and CP. This includes conditions without pressure in the posterior fossa such as tissue loss due to cerebellar atrophy, or pathologies causing a true increase in pressure of the fourth ventricle (isolated fourth ventricle, cystic lesions and neoplasms of the fourth ventricle). Neurologically compromised children pose additional challenges in reaching a definitive diagnosis and hence require a careful regular assessment of their clinical status with additional well-timed imaging with appropriate protocols to allow appropriate treatment when indicated and to avoid morbidity due to delayed diagnosis. We present a rare coexistence of a dermoid tumor within the fourth ventricle in a CP child with PHH and express the dilemmas associated with its management.

Head ultrasonograhy as a screening tool in apparently healthy asymptomatic term neonates.

BACKGROUND: The rate of brain abnormalities in asymptomatic term neonates varies substantially in previous studies. Some of these rates may justify general screening of healthy newborns by head ultrasound (HUS). OBJECTIVES: To assess the incidence of intracranial abnormalities among asymptomatic term newborns with HUS and to detect high-risk populations that might need such screening. METHODS: This was a prospective study in 493 term newborns who underwent HUS and a neurological evaluation during the first 3 days of life. The neurological examination results were unknown to the sonographist and the examiner was blinded to the HUS findings. The abnormal HUS findings were classified as significant or non-significant according to the current literature. RESULTS: Abnormal HUS was found in 11.2% of the neonates. Significant findings were noted in 3.8% of the infants. There was no association between non-structural HUS findings (hemorrhage or echogenicity) and mode of delivery. There was no relationship between any HUS abnormality and birth weight, head circumference and maternal age, ethnicity, education or morbidity. The rate of abnormal neurological, hearing or vision evaluation in infants with a significant abnormal HUS (5.2%) was comparable to the rate in infants with normal or non-significant findings on HUS (3.1%). CONCLUSIONS: There is no indication for routine HUS screening in apparently healthy term neonates due to the relatively low incidence of significant brain abnormalities in these infants in our population.

International survey on the management of skin stigmata and suspected tethered cord.

OBJECTIVES: We designed a survey to investigate current international management trends of neonates with lumbar midline skin stigmata suspicious of tethered cord, among pediatric neurosurgeons, focusing on the lower risk stigmata, simple dimples, deviated gluteal folds, and discolorations. Our findings will enable physicians to assess their current diagnosis routine and aid in clarifying management controversies. STUDY DESIGN: A questionnaire on the proposed diagnostic evaluation of seven case reports, each accompanied by relevant imaging, was distributed by e-mail to members of the International Society for Pediatric Neurosurgery, the European Society for Pediatric Neurosurgery, and via the PEDS server list between March and August 2008. RESULTS: Sixty-two questionnaires, completed by experienced professionals with a rather uniform distribution of experience levels, were analyzed. Forty-eight percent do not recommend any imaging of simple dimples, 30% recommend US screening and 22% recommend MR. Seventy-nine percent recommend imaging of deviated gluteal fold with 30% recommending MR. Ninety-two percent recommend imaging infants with hemangiomas with 74% recommending MR. MR for sinus tracts is recommended by 90% if sacral and by 98% if lumber. Eighty-four percent recommend MR for filar cyst. CONCLUSIONS: Our survey demonstrates that management of low-risk skin stigmata, simple dimple, deviated gluteal fold, and discolorations lacks consensus. In addition, a significant sector of the professional community proposes a work-up of simple dimples, sacral tracts, and filar cysts that contradicts established recommendations. A simple classification system is needed to attain a better approach, enabling correct diagnosis of tethered cord without exposing neonates to unnecessary examinations.

A bizarre reentry phenomenon of distal shunt tip causing shunt malfunction.

INTRODUCTION: We report a bizarre presentation of a distal shunt malfunction in a 5-year-old child with a ventriculoperitoneal shunt. DISCUSSION: The plain radiographs done as a workup for possible shunt malfunction demonstrated the distal shunt tip reentering the abdominal wall from inside the peritoneal cavity. We discuss the possible explanation for the phenomenon. CONCLUSION: We conclude that the case is just another reminder of the fact that shunt malfunctions can have multiple presentations; hence, a regular follow-up with appropriate imaging and high index of suspicion is mandatory in preventing morbidities.

Accelerating Telemedicine for Cerebral Palsy During the COVID-19 Pandemic and Beyond.

The effects of COVID-19 extend beyond the pandemic and are expected to transform healthcare in various ways, many of which remain unknown. With social distancing, telemedicine may become the preferred communication channel between caregivers and patients. Implications for cerebral palsy (CP) children are that this will pose a challenge within this transformation. CP, as a discreet entity, is not considered a risk factor. However, specific comorbidities in individuals with CP, such as chronic lung disease, are known as COVID-19 risk factors. The overall risk for the CP population is probably a factor of age and comorbidities. Staying at home for CP children is both a challenge and an opportunity. Escalation of behavioral conflicts or improved participation and equality within the household may emerge. Interestingly, restricted mobility for the general population narrows existing gaps of ambulation. Telemedicine is the primary way of providing services for chronic conditions during the pandemic and is expected to expand beyond pre-Coronavirus era use. The advantages of telemedicine vary, more so during pandemic times, according to severity, restrictions, and availably of telemedicine. A multidisciplinary therapeutic presence is more accessible with telemedicine, bringing together various specialties and approaches to the child's natural environment. Accessible, continuous care is expected to lower comorbidities, as demonstrated for other chronic conditions. Enhanced monitoring is crucial for younger children as devastating complications, such as hip dysplasia, could be minimized. Last but not least, we will discuss digital health care as an accelerator for participatory medicine, including networked patients and families, as responsible drivers of their health as full partners.

Low-risk lumbar skin stigmata in infants: the role of ultrasound screening.

OBJECTIVE: To reassess the utility and validity of ultrasound (US) screening in infants with lumbar midline skin stigmata (MSS) that may be associated with tethering of the spinal cord. STUDY DESIGN: We conducted a prospective observational study of 254 infants under age 6 months with suspicious dorsal MSS between 2005 and 2007. All infants were examined by US and neurosurgical clinical evaluation, and 50 infants also underwent magnetic resonance imaging (MRI). The US and MRI findings were analyzed for correlation. Associations between the imaging findings and the presence of the low-risk skin lesions simple dimple (113 cases) and deviated gluteal fold (DGF; 44 cases) also were evaluated. RESULTS: Analysis of US and MRI results for the cohort of 50 neonates in whom both examinations were performed showed high concordance. The low-risk group of infants with simple dimple and DGF constituted 157 US procedures, 96% of which were of high quality, providing clear visualization of spinal components. None demonstrated any clinically significant pathological findings. CONCLUSIONS: Our data reaffirm the reliability of US as a screening tool for tethered cord syndrome. Infants with low-risk lesions, such as simple dimple and DGF, may be absolved from US screening, because these findings alone do not indicate underlying pathological lesions. We propose a simplified diagnostic classification system for MSS.

Multidisciplinary surgical approach for cerebrospinal fluid leak in children with complex head trauma.

INTRODUCTION: Post-traumatic cerebrospinal fluid leak from the anterior cranial fossa in children may be isolated or combined with severe facial and calvarial injury. Untreated leak may result with meningitis, hydrocephalus, and abnormal neurocognitive development. PATIENTS AND METHODS: We present nine children, ages 4-16 years, with complicated craniofacial injury treated by a combined subcranial and intracranial approach. A continuous lumbar drainage was kept for several days, and prophylactic antibiotics and anti-convulsive medications were routinely given. A multidisciplinary approach including discussion before surgery about other surgical options (endoscopic extracranial and intracranial alone) were performed. RESULTS: None of the operated children had episodes of meningitis/leak after the combined approach, suggesting that appropriate sealing of the base of the skull has been achieved. There was no mortality, and the long-term follow-up showed good developmental and cosmetic results. Most of the children had significant brain contusions prior to surgery; however, these did not progress as minimal retraction was enabled by the extensive subcranial and intracranial approach. CONCLUSIONS: Child's age, anatomy of the bone, extent of cranial injury, and clinical parameters should be seriously considered when choosing the technical methods as for sealing base of skull and reconstruction of facial/cranial bones. Young age does not seem to be a contraindication to the combined approach, thus, we recommend considering it in extensive base of skull fractures when concomitant cranial, maxillofacial, and orbital fractures coexist, as alternative options may not suffice in these cases.

Dynamic changes in the recovery after traumatic brain injury in mice: effect of injury severity on T2-weighted MRI abnormalities, and motor and cognitive functions.

Memory and neurobehavioral dysfunctions are among the sequelae of traumatic brain injury (TBI). The Neurological Severity Score (NSS) includes 10 tasks and was previously designed to assess the functional status of mice after TBI. The object recognition task (ORT) measures specific episodic memory and is expressed by the percent time spent by an animal at a novel, unfamiliar object (Discrimination Index [DI]). It is an ideal tool for evaluating cognitive function after TBI. The present study sought to validate the use of the NSS and ORT in severe and mild focal TBI in mice, and to confirm that the spontaneous recovery and the radiological abnormalities, shown by T2-weighted magnetic resonance imaging (MRI), are dependent upon injury severity. Mice were subjected to severe and mild closed head injury (NSS at 1 h 7.52 +/- 0.34 and 4.62 +/- 0.14, respectively). NSS was evaluated for 25 days and showed a decrease by 3.86 +/- 0.26 and 2.54 +/- 0.35 units in the severely and mildly injured mice, respectively. ORT revealed DI in severely injured group of 51.7 +/- 6.15%, (vs approximately 75-80% in uninjured animal) on day 3 and 66.2 +/- 6.81% on day 21. In contrast, the mildly injured mice did not show cognitive impairment throughout the same period. The damage seen by MRI at 24 h after injury, strongly correlated with NSS(1h) (R = 0.87, p < 0.001). We conclude that NSS is a reliable tool for evaluation of neurological damage in head-injured mice, NSS(1h) predicts the motor dysfunction, cognitive damage, and brain-damage characteristics as depicted by T2-weighted MRI. The combined assessment of neurobehavioral and cognitive function along with MRI is most useful in evaluating recovery from injury, especially when testing effectiveness of novel treatments or genetic manipulations.

Intrathecal Baclofen Therapy-Practical Approach: Clinical Benefits and Complication Management.

Intrathecal baclofen is an expanding accepted treatment for children with cerebral palsy and other causes of spasticity and dystonia. The aims of this review are therefore to (1) delineate the clinical benefits of intrathecal baclofen therapy in pediatric spasticity and dystonia and (2) increase awareness of the potential complications and emergency management measures of intrathecal baclofen therapy. A current literature review demonstrates the benefits and complications of this minimally invasive device. Practical guides for recognizing acute conditions and management recommendations are included. Intrathecal baclofen is increasingly being used to help individuals attain realistic functional goals. Therefore, families and health care professionals should be aware of potential complications, symptoms, and emergency management.

[Endoscopic third ventriculostomy--a physiological alternative to shunts as treatment for obstructive hydrocephalus in children].

BACKGROUND: The standard treatment for hydrocephalus is a ventriculoperitoneal shunt which is associated with high rate long-term morbidity. Seeking alternative treatments, neuroendoscopic third ventriculostomies (ETV) have been performed in patients with obstructive hydrocephalus. During this procedure, the third ventricular floor is perforated thus bypassing the pathological obstruction. In this procedure, no hardware is left and fluid pressures are more physiologically balanced compared to shunted cases. STUDY GOALS: To present our experience with endoscopic third ventriculostomy (ETV) in patients below the age of 18 years. METHODS: Retrospective analysis of 112 ETV's: in 89 cases (group A) the hydrocephalus was secondary to aqueductal stenosis (primary or secondary). In 23 cases (group B) the hydrocephalus was secondary to other reasons. RESULTS: A total of 70% of patients in group A did not need a shunt during their follow-up in comparison with 56% in group B. In a multivariable analysis--the only significant predictor for failure of the ETV was age below two years at the time of the procedure. Two patients died perioperatively. Both suffered from malignant disseminated tumors. One death was related to oncological reasons; the other death was related to intraventricular bleeding secondary to the procedure. Perioperative morbidity was 23% (decreased to 8% during recent years). No permanent morbidity occurred. CONCLUSIONS: Endoscopic third ventriculostomy is the treatment of choice for obstructive hydrocephalus secondary to aqueductal stenosis among patients older than two years. In younger patients, future studies are needed to prove whether a shunt or a ventriculostomy are the preferred treatment.

Impact of prenatal magnetic resonance imaging on postnatal neurosurgical treatment.

OBJECT: The goal of this study was to determine the importance magnetic resonance (MR) imaging holds as a complementary fetal imaging modality to ultrasonography in deciding postnatal neurosurgical management. METHODS: Between 1999 and 2003, 320 fetal MR imaging studies were performed at a single institution. Twenty-four fetuses were found to have central nervous system abnormalities that could potentially require a neurosurgical intervention. The diagnoses included spinal anomalies (scoliosis, myelomeningocele, and closed spinal dysraphism) and brain anomalies (ventriculomegaly with or without hemorrhage, intracranial cyst, craniosynostosis, and encephalocele). Fourteen of the 24 fetuses underwent surgery based on findings of prenatal MR imaging. In seven cases the pregnancy was terminated, and in three cases conservative follow up continues. CONCLUSIONS: In a variety of brain and spine disorders, prenatal MR imaging can delineate and characterize the abnormality, and thus assist in the diagnosis and in the planning of postnatal surgery and management. This modality provides important multiplanar images and may obviate the need for early postnatal computed tomography or MR imaging. Postnatal management can often be guided by prenatal MR imaging findings.

Multiple bur hole surgery for the treatment of moyamoya disease in children.

OBJECT: The authors' aim in this study was to review their experience in the use of indirect revascularization alone in a series of 14 children with moyamoya disease, in which numerous bur holes and arachnoid openings were made over each affected hemisphere. METHODS: Revascularization through multiple bur holes and arachnoid openings was performed in 14 children (mean age at diagnosis 6.5 years [range 3-15 years]) who suffered from progressive moyamoya disease. The authors performed surgery in a total of 24 hemispheres during 18 procedures. Ten children underwent bilateral multiple bur hole procedures, three underwent a unilateral procedure in the more severely affected hemisphere, and one child had previously undergone an encephaloduroarteriomyosynangiosis on the contralateral side. Ten to 24 bur holes were made in the frontotemporoparietooccipital area of each hemisphere, depending on the site and extent of the disease. Early postoperative perfusion magnetic resonance imaging studies, performed in the five most recent cases, showed restoration of cortical perfusion as early as 3 months, which was confirmed on subsequent angiography studies (performed between 8 and 12 months postoperatively) that showed excellent revascularization of the ischemic brain by external carotid artery collateral vessels. None of the children sustained further ischemic attacks postoperatively. Motor improvement was noted in those who had presented with paresis. A single seizure episode occurred in two patients at 2 weeks and 5 months after surgery; both children had presented with epilepsy. There were no postoperative deaths, and only one complication (an infected lumbar shunt in the patient who required cerebrospinal fluid [CSF] drainage). Five of the 18 procedures were complicated by subcutaneous CSF collections, which resolved with tapping and compressive head dressings; a transient lumbar drain was necessary in one case. CONCLUSIONS: The results obtained in this series suggest that in children with moyamoya disease this simple technique is both effective and safe. Furthermore, it is effective as a sole treatment without supplementary revascularization procedures.

Surgical implications of the thickened pituitary stalk accompanied by central diabetes insipidus.

OBJECT: The authors discuss the indications for and timing of a diagnostic neurosurgical procedure in children with diabetes insipidus (DI) and a thickened pituitary stalk (TPS) on magnetic resonance (MR) imaging. METHODS: Seven children with a TPS who presented with DI eventually underwent surgery for diagnostic purposes. The ages at onset of DI were 6 to 16 years, and the follow-up period until surgery was 26.9 +/- 11.9 months. In four of seven children, the stalk appeared normal on the first MR image, but it was thickened and variably enhancing on later images in all instances. The reason for eventual surgery was endocrinological deterioration in two of seven children, radiological progression in two children, and a combination of the two in three children. Three children experienced visual disturbances and four children had optic nerve, chiasma, or hypothalamus involvement. All children suffered additional endocrinological abnormalities pursuant to the initial DI. A definitive diagnosis was achieved in six of seven children: germinomas in five and Langerhans cell histiocytosis in one. One child had lymphocytic infiltrate. None of the children deteriorated neurologically or endocrinologically after the operation. On follow up, vision deficit was irreversible in all children who demonstrated visual abnormalities before treatment. CONCLUSIONS: Surgery should be performed in children with a TPS and DI for early diagnosis and disease-oriented therapy when there is further endocrinological, radiological, or clinical deterioration. The complication rate is low in open biopsies, and histological diagnosis is achieved in most of the cases. All children who present with central DI must undergo head MR imaging, and even if results are normal, close radiological and clinical follow up is mandatory.

A single administration of the peptide NAP induces long-term protective changes against the consequences of head injury: gene Atlas array analysis.

The femtomolar-acting eight-amino-acid peptide (NAP), derived from activity-dependent neuroprotective protein (ADNP), provides long-term protection against the deleterious effects of closed head injury (CHI) in mice. Fifteen minutes after injury, mice were divided into two groups, control and NAP-treated and a single subcutaneous injection of NAP or vehicle was administered. A third group served as sham-treated (not subjected to head trauma). Each mouse was assessed for its clinical function, using neurological severity score, at various time intervals following CHI, up to 30-45 d. Total cerebral cortex RNA was prepared from the site of injury of CHI mice, and from parallel regions in peptide-treated and sham brains. RNA was then reversed transcribed to yield radioactive cDNA preparations that were hybridized to Atlas array membranes containing 1200 cDNAs spots. Comparison of sham-treated individual mice showed differential expression levels of at least 15 mRNA species. Furthermore, results indicated that one of the genes that did not change among individuals but specifically increased after CHI and decreased after NAP treatment was the cell surface glycoprotein Mac-1 (CD11B antigen). Thus, Mac-1 is suggested as a marker for the long-term outcome of head injury and as a potential target for NAP protective actions.

Endoscopic third ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage.

OBJECT: In this study the authors evaluate the safety, efficacy, and indications for endoscopic third ventriculostomy (ETV) in patients with a history of subarachnoid hemorrhage or intraventricular hemorrhage (IVH) and/or cerebrospinal fluid (CSF) infection. METHODS: The charts of 101 patients from seven international medical centers were retrospectively reviewed; 46 patients had a history of hemorrhage, 42 had a history of CSF infection, and 13 had a history of both disorders. All patients experienced third ventricular hydrocephalus before endoscopy. The success rate for treatment in these three groups was 60.9, 64.3, and 23.1%, respectively. The follow-up period in successfully treated patients ranged from 0.6 to 10 years. Relatively minor complications were observed in 15 patients (14.9%), and there were no deaths. A higher rate of treatment failure was associated with three factors: classification in the combined infection/hemorrhage group, premature birth in the posthemorrhage group, and younger age in the postinfection group. A higher success rate was associated with a history of ventriculoperitoneal (VP) shunt placement before ETV in the posthemorrhage group, even among those who had been born prematurely, who were otherwise more prone to treatment failure. The 13 premature infants who had suffered an IVH and who had undergone VP shunt placement before ETV had a 100% success rate. The procedure was also successful in nine of 10 patients with primary aqueductal stenosis. CONCLUSIONS: Patients with obstructive hydrocephalus and a history of either hemorrhage or infection may be good candidates for ETV, with safety and success rates comparable with those in more general series of patients. Patients who have sustained both hemorrhage and infection are poor candidates for ETV, except in selected cases and as a treatment of last resort. In patients who have previously undergone shunt placement posthemorrhage, ETV is highly successful. It is also highly successful in patients with primary aqueductal stenosis, even in those with a history of hemorrhage or CSF infection.