Pediatric Cervical Spine Injuries.

Objective Pediatric cervical spine injuries are rare and account for 1 to 2% of all pediatric spine injuries. There is a paucity of data on pediatric cervical spine injuries in developing countries like India. The purpose of this study is to review and analyze our 5 years of experience with pediatric cervical spine injuries. Methods All the available medical records over the 5 years were reviewed retrospectively. The data was analyzed to know the epidemiology, mechanism of injury, injury patterns, management, and outcome. The patients were divided into two groups: 0 to 9 years and 10 to 18 years. Results Seventy-five eligible records were included in our study. The incidence of cervical spine injuries was significantly lower in younger children than the older ones ( p < 0.042). The most common mechanism of injury was fall from height: 33 (44%) patients followed by road traffic accidents: 27 (36%) patients. The involvement of the upper cervical spine was significantly higher in younger children ( p < 0.001). Fractures with subluxation were the most common pattern of injury, observed in 35 (47%) patients. However, fractures with subluxation were uncommon in younger children compared with older children ( p < 0.04). Spinal cord injury without radiographic abnormality (SCIWORA) was observed in 42% of younger children compared with 8% of older children ( p < 0.02). Thirty (40%) patients were managed surgically; anterior cervical corpectomy with fusion was the most commonly performed procedure in 19 (63%) patients. The overall mortality was 20%. Conclusion The results of our study revealed predominant involvement of the upper cervical spine in children younger than 10 years of age. SCIWORA was documented in both the age groups with a significantly higher incidence in younger children. The instrumentation and fusion techniques in children are safe; however, developing pediatric spine needs special considerations.

Radiation-induced Supratentorial Osteosarcoma Following Curative Treatment of Infratentorial Ependymoma in a Child.

The development of secondary neoplasms following therapeutic cranial irradiation is rare and quite often lethal. Meningiomas, sarcomas, and high-grade gliomas are the most common tumors that manifest as a result of radiation therapy. We report the case of an 11-year-old child who presented with symptoms of supratentorial space-occupying lesion 7 years after curative surgery and cranial irradiation for a posterior fossa ependymoma. Magnetic resonance imaging of the brain revealed a right-sided temporoparietal dural-based contrast-enhancing lesion with evidence of overlying bone and skin involvement. The histological report of ependymoma from the previous surgery led us to suspect that we were dealing with a recurrence until the histopathology of the second surgery revealed highly malignant osteosarcoma. The child recovered fully and underwent chemotherapy, but ultimately succumbed to the disease. We report this case to highlight the importance of recognizing these neoplasms and to review its management.

A Comparative Analysis Between Four-Quadrant Osteoplastic Decompressive Craniotomy versus Conventional Decompressive Craniectomy for Traumatic Brain Injury.

OBJECTIVE: Primary decompressive craniectomy (DC) is indicated to evacuate the hematoma and reduce intracranial pressure in traumatic brain injury (TBI). However, there are a myriad of complications because of absence of the bone flap. A novel technique, four-quadrant osteoplastic decompressive craniotomy (FoQOsD) retains the bone flap while achieving adequate cerebral decompression. METHODS: A single-center randomized controlled trial of 115 patients with TBI needing decompressive surgery was conducted. Of these patients, 59 underwent DC and 56 underwent FoQOsD. The primary outcome determined was functional status at 6 months using the Glasgow Outcome Scale-Extended. RESULTS: No significant differences were identified in baseline characteristics between both groups. Mean Glasgow Outcome Scale-Extended score was comparable at 6 months (4.28 in DC vs. 4.38 in FoQOsD; P = 0.856). Further, 22 of 58 patients in the DC group had died (38%) compared with 25 of 55 patients in the FoQOsD group (44.6%) (odds ratio [OR], 1.19; 95% confidence interval [CI], 0.6-2.36; P = 0.6) (1 patient lost to follow-up in each group). A favorable outcome was seen in 56.8% of patients in the DC group versus 54.4% of patients in the FoQOsD group (P = 0.74). Presence of intraventricular hemorrhage and subarachnoid hemorrhage (OR, 7.17; 95% CI, 1.364-37.7; P = 0.020), opposite side contusions (OR, 3.838; 95% CI, 1.614-9.131; P = 0.002) and anisocoria (OR, 3.235; 95% CI, 1.490-7.026; P = 0.003) preoperatively were individual factors that played a significant role in final outcome. CONCLUSIONS: FoQOsD is as efficacious as conventional DC with the added benefit of avoiding a second surgery. The procedure is associated with better cosmesis and fewer complications.

Clinico-Radiological Outcome Analysis in Craniovertebral Junction Diseases: An Institutional Experience of 38 Patients in a Tertiary Care Centre.

BACKGROUND: Craniovertebral junction diseases, although considered rare, are common in northern parts of India. This study was conducted to evaluate the clinico-radiologic and surgical outcome of patients with a minimum follow-up of 1 year. Our study also compared bony fusion among various techniques of posterior fusion. METHODS: This retrospective study was performed with 38 patients who met the inclusion criteria for analysis. These patients were contacted by telephone and letters, and their clinical examination and radiologic investigations were performed at a follow-up visit. The preoperative, postoperative, and follow-up clinical evaluations of the patients were done using the Nurick grading system. RESULTS: The age range was 4-60 years with an average of 20.5 years. There were 31 male and 7 female patients, with a male:female ratio of 4.43:1. There were 13 cases of fixed atlantoaxial dislocation (AAD), 17 cases of mobile AAD, 6 cases of traumatic AAD, and 2 cases of postinfective AAD. The majority of these patients (n = 29; 76.31%) had neck pain and cerebellovestibular disturbances (n = 27; 71.1%). Sphincter disturbances were observed in 9 patients. An increase in craniovertebral angle was observed in postoperative period in all patients. Initially, 84% of the patients had a poor Nurick grade; this was reduced to 28% after the surgical intervention. One hundred percent bony fusion was attained in patients who underwent rigid fixation technique, and 80% was attained using a semirigid fixation technique. CONCLUSIONS: The key to successful management of craniovertebral junction disease is individualized selection of judicious surgical intervention from various available techniques.

Revisiting epidermal growth factor receptor in glioblastoma multiforme: does it play a role in response to therapy?

BACKGROUND AND AIM: Glioblastoma multiforme (GBM) are the most aggressive class of cancer of central nervous system with hallmark characteristics that include rampant proliferation, necrosis, and endothelial proliferation. Epidermal growth factor receptor (EGFR) has been implicated as the primary contributor to glioblastoma initiation and succession. The present study was designed to evaluate EGFR protein expression in GBM as predictor of response to therapy and survival. MATERIALS AND METHODS: Epidermal growth factor receptor was assessed by immunohistochemistry as a percentage of positive tumor cells in hot spots (10 high-power fields). The study group comprised of 35 cases of GBM. All cases underwent surgical resection and subsequently underwent radiotherapy (n = 17) or radiotherapy with adjuvant temozolomide chemotherapy (n = 18). Immediate response to therapy was assessed at 3 months using World Health Organization response evaluation criteria in solid tumors criteria and cases followed up for survival. RESULTS: Twenty-four cases (68.6%) expressed EGFR while 11/35 (31.4%) cases were negative. Response to therapy was evident in 21/35 cases (60.0%) and 14/35 were (40.0%) nonresponders. Mean EGFR protein expression in responders was 37.23 ± 33.70 and in nonresponders was 59.5 ± 39.46 (P = 0.542). The percentage of responders which were EGFR negative was 72.7% and while response in EGFR positive cases was observed in 54.2%. Mean survival in EGFR positive and negative GBM was 394.37 ± 189.11 and 420.54 ± 191.23 days, respectively. CONCLUSION: The EGFR negative cases appear to respond better to therapy, however, the difference is not statistically significant (P = 0.298). Further, EGFR protein expression does not play a definitive role in predicting survival. This is an original study evaluating EGFR in terms of therapeutic response.

Comparative evaluation of 3-dimensional pseudocontinuous arterial spin labeling with dynamic contrast-enhanced perfusion magnetic resonance imaging in grading of human glioma.

INTRODUCTION: The study was performed to compare dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) with 3-dimensional (3D) pseudocontinuous arterial spin labeling (PCASL) MRI in gliomas with an aim to see whether arterial spin labeling (ASL)-derived cerebral blood flow (CBF) values can be used as an alternative to DCE-MRI for its grading. MATERIALS AND METHODS: Sixty-four patients with glioma (37 male; mean age, 43 years; 38 high grade and 26 low grade) underwent 3D-PCASL and DCE-MRI. The DCE indices (relative cerebral blood volume, rCBV; relative CBF, rCBF; permeability, k and kep; and leakage, ve) and ASL (absolute and rCBF) values were quantified from the tumors. Student independent t test was used to compare ASL and DCE-MRI indices. Pearson correlation was used to see correlation between DCE- and ASL-derived CBF values in tumor and normal parenchyma. RESULTS: On Student t test, neither ASL-derived absolute CBF (P = 0.78) nor rCBF (P = 0.12) values were found to be significantly different in 2 groups, whereas DCE indices except ve were significantly higher in high-grade gliomas. Arterial spin labeling-derived rCBF values weakly correlated with DCE-derived rCBF values, whereas these did not show correlation in normal grey (P = 0.12, r = 0.2) and white (P = 0.26, r = 0.14) matter regions. CONCLUSIONS: Three-dimensional pseudocontinuous arterial spin labeling does not appear to be a reliable technique in the current form and may not be a suitable replacement for DCE in grading of glioma.

Role of magnetic resonance ventriculography in multiloculated hydrocephalus.

OBJECT: In this paper the authors' goal was to investigate the clinical usefulness of Gd-enhanced MR ventriculography (MRV) in pediatric patients affected by multiloculated hydrocephalus. METHODS: Eighteen patients (11 boys and 7 girls, age range 2-14 months) with a diagnosis of multiloculated hydrocephalus were included in the study. After injection of gadodiamide (0.02-0.04 mmol) into the lateral ventricle by tapping the anterior fontanel, sagittal, coronal, and axial T1-weighted MR images were acquired. The location of the septations and the sites of obstruction of CSF flow were assessed. Postoperative MRV was obtained to confirm the results of endoscopic treatment in most complex cases. RESULTS: No adverse events were observed after injection of contrast medium into the ventricular system. Preoperative MRV accurately defined the exact morphology of septae and ventricular walls in all cases. In 1 case the diagnosis of multiloculated hydrocephalus was ruled out. Sites of obstruction of CSF flow within the ventricular system were also well established. In 4 cases the multiple compartments were proven to intercommunicate. Postoperative MRV was useful in assessing the functional status of third ventriculostomy, aqueductoplasty, and other endoscopic fenestrations. CONCLUSIONS: Magnetic resonance ventriculography is a safe, effective, and reliable technique. The accurate definition of the anatomy of the ventricles and the site of obstruction in multiloculated hydrocephalus can help to plan the most appropriate treatment and minimize the number of procedures. Although MRV is also useful during postoperative follow-up to determine the results of endoscopic treatment, it should be limited to particularly complex cases, due to its invasiveness.

Diffusion tensor tractography indices in patients with frontal lobe injury and its correlation with neuropsychological tests.

OBJECTIVES: Diffusion tensor tractography (DTT) was performed to quantify diffuse axonal injury (DAI) in major white matter (WM) fiber bundles (FBs) of patients with frontal lobe injury and to correlate these changes with neuropsychological tests (NPT) at 6 month follow-up. PATIENTS AND METHODS: DTT was performed in 21 patients with moderate traumatic brain injury (TBI) within week and after 6 month follow-up, and in controls. DTI indices were calculated from the entire FBs in patients as well as controls. Bonferroni multiple comparisons Post hoc test was performed for determining the changes in DTI indices. Paired t-test was performed between DTI indices at baseline and follow-up. Pearson's correlation was performed between NPT scores and DTI indices. RESULTS: Significant changes in DTI indices were observed in some of the FBs as compared to controls which incompletely recovered at 6 month follow-up. DTI indices of different WM FBs correlated significantly with some of the NPT. CONCLUSION: We conclude that DTT based quantification helps in assessment of DAI in patients with moderate frontal lobe injury. Some of the FBs recover partially at 6 month follow-up and correlate with NPT scores.

T2*-weighted MR angiography substantially increases the detection of hemorrhage in the wall of brain abscess: implications in clinical interpretation.

INTRODUCTION: The purpose of the present study was to identify the true prevalence of hemorrhage in the abscess using T2*-weighted angiography (SWAN) imaging and to study its influence on diffusion tensor imaging (DTI) metrics. METHODS: Fifteen patients of brain abscess underwent conventional, SWAN, and DT imaging on a 3-T MRI followed by its confirmation with histology. DTI metrics were quantified by region-of-interest analysis on hemorrhagic and non-hemorrhagic regions of the abscess wall. Prussian blue staining was performed on excised abscess walls to confirm hemorrhage on histology. RESULTS: Eleven of 15 patients showed evidence of hemorrhage on both Prussian blue staining as well as SWAN imaging. Fractional anisotropy (FA) and linear anisotropy (CL) values were significantly higher, while spherical anisotropy was significantly lower in hemorrhagic compared to non-hemorrhagic regions of the abscess wall. CONCLUSION: Hemorrhage in the abscess wall is a common feature and may not always indicate neoplasm. The presence of intracellular iron in addition to concentrically laid collagen fibers may have synergistic effect on FA and CL values in the abscess wall. Inclusion of SWAN to MRI protocol will define the true prevalence of hemorrhage in brain abscess.

Giant unusual shaped chronic subdural hematoma in a patient with untreated congenital hydrocephalus.

Subdural hematoma is a well known complication of ventriculoperitoneal shunt insertion for hydrocephalus and usually spreads out over the cerebral convexity, and appears as a crescent shaped lesion on imaging. Chronic subdural hematoma in a case of untreated compensated congenital hydrocephalus has not been reported in English literature. We report the rare case of an adult with congenital hydrocephalus with a huge unusual shaped hemispheric subdural hematoma.

Surgical outcome of tuberculous meningitis hydrocephalus treated by endoscopic third ventriculostomy: prognostic factors and postoperative neuroimaging for functional assessment of ventriculostomy.

OBJECT: Endoscopic third ventriculostomy (ETV) is increasingly being used as an alternative treatment for post-tuberculous meningitis (TBM) hydrocephalus. The aim of this study was to affirm the role of ETV in patients with TBM hydrocephalus and also to study the usefulness of cine phase-contrast MR imaging (cine MR imaging) for functional assessment of the ETV stoma. An additional goal was to identify factors that influence the outcome of ETV, so as to define patients with TBM hydrocephalus in whom ETV is warranted. METHODS: Twenty-six patients with TBM hydrocephalus treated with ETV were evaluated clinically and with cine MR imaging postoperatively. The duration of follow-up ranged from 1 to 15 months. The authors evaluated flow void changes in the floor of the third ventricle and analyzed parameters from the preoperative data, which they then used as a basis for comparison between endoscopically successful and endoscopically unsuccessful cases. RESULTS: The overall success rate of ETV in TBM hydrocephalus was 73.1% in this case series. Cine MR imaging showed a sensitivity of 94.73% and specificity of 71.42% for the functional assessment of third ventriculostomy in these patients, with the efficacy being maintained during follow-up. The outcome of ETV showed a statistically significant correlation with the stage of illness and presence of intraoperative cisternal exudates. Although duration of symptoms and duration of preoperative antituberculous therapy (ATT) appeared to influence the outcome, their correlation with outcome was not statistically significant. CONCLUSIONS: Endoscopic third ventriculostomy should be considered as the first surgical option for CSF diversion (that is, before shunt surgery) in patients with TBM hydrocephalus. Cine MR imaging is a highly effective noninvasive tool for the postoperative functional assessment of stomata. Patients who presented with a history of longer duration and those who were administered preoperative ATT for a longer period had a better outcome of endoscopic treatment. Outcome was poorer in patients who presented with higher stages of illness and in those in whom cisternal exudates were observed intraoperatively.