Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS).

PURPOSE: The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis. METHODS: We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex. RESULTS: Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up. CONCLUSION: ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

Minimal exposure maximal precision ventriculoperitoneal shunt: how I do it.

BACKGROUND: Ventriculoperitoneal shunt is among the most frequent neurosurgical procedures, complicated by infection and obstruction. The first is influenced by number of skin incisions, catheter exposure and manipulation, and the latter by catheter position. METHOD: Presenting our neuronavigated laparoscopic-assisted minimal exposure shunt technique performed on 40 consecutive adults. No patient presented infection or distal catheter migration (mean follow-up 12 months). Ventricular catheter malpositioning associated with electromagnetic neuronavigation inaccuracy occurred in two patients with slit ventricles. CONCLUSION: This technique demonstrates low infection/malfunction rate, postoperative pain, and cosmetic advantages. Limiting factors are availability of laparoscopic surgeons and neuronavigation if not familiar with the approach.

Nerve transfers from branches to the flexor carpi radialis and pronator teres to reconstruct the radial nerve.

PURPOSE: To present our method and results for transferring branches of the median nerve for radial nerve palsy or posterior cord lesions. METHODS: We transferred 1 branch to the pronator teres to the branch to the extensor carpi radialis longus muscle and transferred the branch to the flexor carpi radialis to the posterior interosseous nerve. We carried out these transfers in 6 patients with radial nerve palsy or posterior cord lesions. We reviewed functional outcomes, Disabilities of the Arm, Shoulder and Hand scores, and Patient Evaluation Measure scores. RESULTS: After 20 months of follow-up evaluation, all patients had recovered extensor carpi radialis longus activity of M4. Activity of the extensor carpi ulnaris was M3 in 2 patients and M4 in 4 patients. Extensor pollicis longus activity was M4 in all 6 cases. Metacarpophalangeal extension was M4 in 4 cases and M3 in 2 cases. The mean Disabilities of the Arm, Shoulder, and Hand score was 26 (range, 7-43), and the mean Patient Evaluation Measure score was 34 (range, 24-53). CONCLUSIONS: Selective independent synergistic transfer of median nerve fascicles to the radial nerve branches has shown excellent results in the treatment of severe lesions of the radial nerve. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Obstructive Sleep Apnea and Oxygenation in Very Old Adults: A Propensity-Score Match Study.

OBJECTIVES: The prevalence of obstructive sleep apnea (OSA) escalates with advancing age. Although the apnea-hypopnea index (AHI) is the standard measure for assessing OSA severity, it does not account for additional oximetric parameters that may influence disease progression in older adults. This study aimed to evaluate disparities in respiratory polygraphy/polysomnography parameters among patients with OSA, stratified by age and sex. DESIGN: Retrospective propensity score-matched study. SETTING AND PARTICIPANTS: Sleep unit of a university hospital; 11,747 participants, 210 aged 80 years or older. METHODS: Propensity score matching was used to establish 4 age cohorts, with the 210 oldest adults serving as the reference group. Primary outcome variables included the total sleep time with oxygen saturation (SaO2) below 90% (T90), average SaO2, minimum SaO2, and AHI. The association between T90 and AHI, as well as the severity of OSA, was assessed across the 4 age categories. RESULTS: Despite comparable AHI scores, the oldest patients with OSA exhibited the highest T90 and the lowest SaO2 levels compared to younger counterparts. The proportion of patients with severe OSA and T90 in the highest quartile increased with age: 12.5% in young adults, 14.8% in adults, 21.7% in the old, and 34% in the very old participants (P < .001). old and very old patients had a greater likelihood of being in the most severe OSA category compared to the younger ones, with odds ratios (OR) 2.57 (95% CI 1.42-4.65) and 5.52 (95% CI 3.06-9.97), respectively. These patterns were more pronounced in women of advanced age, indicating a sex-specific variation in disease severity with increasing age. CONCLUSIONS AND IMPLICATIONS: Old patients with OSA, particularly women, demonstrate elevated T90 and reduced SaO2 levels, irrespective of AHI, indicating a hypoxemia increased risk. The diagnostic criteria, management, and outcomes for OSA may require adaptations to address the unique needs of very old populations.

Cerebral hemodynamic changes in obstructive sleep apnea syndrome after continuous positive airway pressure treatment.

BACKGROUND: Patients with obstructive sleep apnea syndrome (OSAS) are at increased risk for cerebrovascular diseases. The underlying mechanisms remain obscure. It may occur through a reduction in cerebral vascular reactivity. Continuous positive airway pressure (CPAP) is effective in reducing the occurrence of apneas. We hypothesized that treatment with CPAP improves cerebral vascular reactivity. METHODS: This is a prospective study with OSAS patients. The apnea test (ApT) was calculated as an increase of mean artery velocity during apnea: [Artery velocity in apnea minus Resting artery velocity]/Resting artery velocity expressed as percentage. After 2 years of CPAP treatment, the test was repeated. RESULTS: Seventy-six patients represented the study pool. After 2 years of treatment with CPAP, we were able to conduct a reassessment in 65 patients. Of the 65 patients who finished the clinical study, 56 were men, and 9 were women, with an average age of 48.1 ± 10.4 years. There was an improvement in the ApT after CPAP treatment (30.8 ± 12.1 vs 39.8 ± 15.1; p:0.000). The values of cerebral blood flow velocities, diastolic blood pressure in apnea, and basal heart rate decreased. CONCLUSIONS: Cerebral vascular reactivity in OSAS patients measured by ApT improved after 2 years of CPAP.

Microsurgical management of distal anterior cerebral artery aneurysms: from basic to complex, a video review of four cases.

BACKGROUND: Distal anterior cerebral artery (DACA) aneurysms represent 2-9 % of intracranial aneurysms. They are often more amenable to surgical rather than endovascular treatment due to the size of parent vessels. METHOD: We illustrate surgical approaches for DACA aneurysms arising from different segments of the anterior cerebral artery. Cases range from simple unruptured aneurysms to complex ruptured aneurysms requiring reconstruction and intracranial bypass. CONCLUSION: The interhemispheric approach typically provides an adequate surgical corridor for surgical clipping of DACA aneurysms. Patient positioning, image guidance, and preoperative angiography help maximize safety and efficacy of surgery.

Cerebral hemodynamic changes at basilar artery in obstructive sleep apnea syndrome after continuous positive airway pressure treatment.

BACKGROUND: Cerebral vasoreactivity in obstructive sleep apnea syndrome is altered. Continuous positive airway pressure is effective in the reduction of the occurrence of apneas. We studied whether this treatment also improves cerebral vasoreactivity. METHODS: The breath-holding maneuver was performed and assessed by apnea test with transcranial Doppler in the basilar artery. After 2 years of continuous positive airway pressure treatment, the test was repeated. RESULTS: There is an improvement in the apnea test after continuous positive airway pressure. There are increases in the pulsatility index, diastolic blood pressure, and basal heart rate. The improvement in the apnea test depends on the body mass index of the patient. CONCLUSIONS: Cerebral vasoreactivity as measured by the apnea test improves after 2 years of continuous positive airway pressure. This improvement depends of the body mass index of the patient.

Neurosurgical training and education - General European certification is supported: Results of an EANS survey.

Introduction: Delivering high-quality Neurosurgical care is dependent on excellence in neurosurgical training. Across Europe requirements of these programs vary from state to state. This study aims to determine satisfaction with these programs and views towards a unified certifications process for Neurosurgical training. Methods: An electronic survey was disseminated to European trainees, Fellows and Consultants from 11/21 to 02/22. For descriptive purposes, categorical variables, i.e. Age, Gender, year of training, country and outcomes were analyzed. Results: A total of 339 responses were submitted, representing all EANS member states except for Cyprus and Macedonia. Seventy-five were <30 years, 82.3% were male, ∼60% were Specialists, and twenty-four per cent held a fellowship with the European Board of Neurosurgery. 80.2% believed that a joint standardized Neurosurgical certificate in Europe is necessary, with 31.6% believing residency had not prepared them fully as a neurosurgeon. Conclusion: This survey shows that views towards general European-wide certification is positive and that there is ongoing consensus that there is concern with some aspects of training and high variability in its delivery across Europe.

Cartilage Defect Treatment Using High-Density Autologous Chondrocyte Implantation (HD-ACI).

Hyaline cartilage's inability to self-repair can lead to osteoarthritis and joint replacement. Various treatments, including cell therapy, have been developed for cartilage damage. Autologous chondrocyte implantation (ACI) is considered the best option for focal chondral lesions. In this article, we aimed to create a narrative review that highlights the evolution and enhancement of our chondrocyte implantation technique: High-Density-ACI (HD-ACI) Membrane-assisted Autologous Chondrocyte Implantation (MACI) improved ACI using a collagen membrane as a carrier. However, low cell density in MACI resulted in softer regenerated tissue. HD-ACI was developed to improve MACI, implanting 5 million chondrocytes per cm2, providing higher cell density. In animal models, HD-ACI formed hyaline-like cartilage, while other treatments led to fibrocartilage. HD-ACI was further evaluated in patients with knee or ankle defects and expanded to treat hip lesions and bilateral defects. HD-ACI offers a potential solution for cartilage defects, improving outcomes in regenerative medicine and cell therapy. HD-ACI, with its higher cell density, shows promise for treating chondral defects and advancing cartilage repair in regenerative medicine and cell therapy.

Clinical and radiographic characteristics of sacral arteriovenous fistulas: a multicenter experience.

OBJECTIVE: Available data on management of sacral arteriovenous fistulas (sAVFs) are limited to individual case reports and small series. Management includes observation, endovascular embolization, or surgical ligation, with no clear guidelines on the optimal treatment modality. The authors' objective was to report their multiinstitutional experience with management of sAVF patients, including clinical and radiographic characteristics and postprocedural outcomes. METHODS: The electronic medical records of patients with a diagnosis of spinal arteriovenous fistula treated from January 2004 to December 2019 at the authors' institutions were reviewed, and data were summarized using descriptive statistics, including percentage and count for categorical data, median as a measure of central tendency for continuous variables, and interquartile range (IQR) as a measure of dispersion. RESULTS: A total of 26 patients with sAVFs were included. The median (IQR) age was 65 (57-73) years, and 73% (n = 19) of patients were male. Lower-extremity weakness was the most common presenting symptom (n = 24 [92%]), and half the patients (n = 13 [50%]) reported bowel and bladder sphincter dysfunction. The median (IQR) time from symptom onset to treatment was 12 (5.25-26.25) months. Radiographically, all patients had T2 hyperintensity at the level of the conus medullaris (CM) (n = 26 [100%]). Intradural flow voids were identified in 85% (n = 22) of patients. The majority of the lesions had a single identifiable arterial feeder (n = 19 [73%]). The fistula was located most commonly at the S1 level (n = 13 [50%]). The site where the draining vein connects to the pial venous plexus was seen predominantly at the lumbar level (n = 16 [62%]). In total, 29 procedures were performed: 10 open surgeries and 19 endovascular embolization procedures. Complete occlusion was achieved in 90% (n = 9) of patients after open surgery and 79% (n = 15) after endovascular embolization. Motor improvement was seen in 68% of patients (n = 15), and bladder and bowel function improved in 9 patients (41%). At last follow-up, 73% (n = 16) of patients had either resolution or improvement of the pretreatment intramedullary T2 signal hyperintensity. CONCLUSIONS: T2 hyperintensity of the CM and a dilated filum terminale vein are consistent radiographic signs of sAVF, and delayed presentation is common. Complete occlusion was achieved in almost all patients after surgery, and endovascular embolization was effective in 70% of the patients. Further studies are needed to determine the best treatment modality based on case-specific characteristics.

Giant frontal sinus osteoma and its potential consequences: illustrative case.

BACKGROUND: Osteomas of the paranasal sinuses are benign, slow-growing bone tumors that can cause a variety of clinical features depending on their size and location. Most osteomas are asymptomatic and located in the frontal sinus. In rare cases, they may grow to extend into the cranial or orbital cavities, resulting in atypical presentations. The authors presented an aggressive case of a frontoethmoidal sinus osteoma with intracranial extension of an inflammatory sinonasal polyp. OBSERVATIONS: A 30-year-old man with a history of chronic sinusitis presented to the hospital after three episodes of loss of consciousness, chronic worsening of headache, and decreased sense of smell. Rhinoscopic examination showed mucosal polyps arising from the infundibulum and the superior meatus. Computed tomography showed a fibro-osseous mass in the left frontal sinus. Subsequent brain magnetic resonance imaging with and without contrast revealed a large, septated intracranial left frontal lesion approximately 6.5 cm in diameter that was compressing the underlying brain parenchyma. LESSONS: Intracranial extension of frontal sinus osteomas can have dire neurological implications. Early detection of lesions obstructing the paranasal sinuses outlet could prevent intracranial extension of the disease. The surgical approach to such tumors may be endonasal, open cranial, or a combination of both.

Patellar Tendon Structural Adaptations Occur during Pre-Season and First Competitive Cycle in Male Professional Handball Players.

BACKGROUND: While there is evidence that tendon adapts to training load, structural alterations in the patellar tendon in response to training loads are still unclear. The aim of this study is to identify changes in patellar tendon structure throughout pre-season and after finalizing the first competitive cycle. METHODS: Nineteen professional handball players participated in the aforesaid cross-sectional study, in which patellar tendon scan and counter movement jump (CMJ) performance were conducted. Measurements were taken on the first and last day of pre-season training, and at the end of the first competitive cycle. RESULTS: The results revealed that variation on the tendon structure occurred, mainly at the end of pre-season training; for injured tendons this occurred at the proximal (Right p = 0.02), distal (Right p = 0.01), and (Left p = 0.02) tendon, while changes in healthy tendons occurred at the mid (Left p = 0.01) and distal tendon (Right p = 0.01). At the end of the first competitive cycle, changes were observed in the distal injured tendon (p = 0.02). CONCLUSION: Patellar tendon shows greater structural change after completing pre-season training than at the end of the first competitive cycle, from which it may be inferred that gradual loading during pre-season training allows the tendon to adapt and potentially decrease the onset of patellar tendinopathy.

High-Density Autologous Chondrocyte Implantation as Treatment for Ankle Osteochondral Defects.

PURPOSE: Two-year follow-up to assess efficacy and safety of high-density autologous chondrocyte implantation (HD-ACI) in patients with cartilage lesions in the ankle. DESIGN: Twenty-four consecutive patients with International Cartilage repair Society (ICRS) grade 3-4 cartilage lesions of the ankle were included. Five million chondrocytes per cm2 of lesion were implanted using a type I/III collagen membrane as a carrier and treatment effectiveness was assessed by evaluating pain with the visual analogue scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at baseline, 12-month, and 24-month follow-up, together with dorsal and plantar flexion. Magnetic resonance observation for cartilage repair tissue (MOCART) score was used to evaluate cartilage healing. Histological study was possible in 5 cases. RESULTS: Patients' median age was 31 years (range 18-55 years). Median VAS score was 8 (range 5-10) at baseline, 1.5 (range 0-8) at 12-month follow-up, and 2 (rang e0-5) at 24-month follow-up (P < 0.001). Median AOFAS score was 39.5 (range 29-48) at baseline, 90 (range 38-100) at 12-month follow-up, and 90 (range 40-100) at 24-month follow-up (P < 0.001). Complete dorsal flexion significantly increased at 12 months (16/24, 66.7%) and 24 months (17/24, 70.8%) with regard to baseline (13/24, 54.2%) (P = 0.002). MOCART at 12- and 24-month follow-ups were 73.71 ± 15.99 and 72.33 ± 16.21. Histological study confirmed that neosynthetized tissue was cartilage with hyaline extracellular matrix and numerous viable chondrocytes. CONCLUSION: HD-ACI is a safe and effective technique to treat osteochondral lesions in the talus, providing good clinical and histological results at short- and mid-term follow-ups.

Primary Central Nervous System Lymphoma in a Patient on Adalimumab Therapy for Chronic Plaque Psoriasis.

BACKGROUND: Adalimumab (Humira) is a recombinant human monoclonal antibody against tumor necrosis factor alpha, which works by blocking the interaction of tumor necrosis factor alpha with its cell-surface receptors, thereby limiting the progression of inflammatory pathways. Its use is approved for several autoimmune conditions, including chronic plaque psoriasis, for which it has been prescribed as a first-line biologic treatment. Increased risks of malignancy, particularly nonmelanoma skin cancer and non-central nervous system lymphomas, have been reported with use of this drug; however, there have been no reports of central nervous system lymphomas. CASE DESCRIPTION: A 43-year-old man presented for evaluation following recent speech difficulty and a generalized tonic-clonic seizure. His medical history was significant for plaque psoriasis, for which he had been receiving treatment with adalimumab for 4 months. Magnetic resonance imaging scan of the brain with contrast agent showed a well-defined rounded enhancing lesion in the left temporal lobe with circumferential vasogenic edema. Mass effect was noted. Computed tomography scan of the chest, abdomen, and pelvis was unremarkable. He underwent excisional biopsy, and the preliminary intraoperative pathology report revealed a diagnosis of high-grade lymphoma. Subsequent analysis of morphology and immunophenotyping was consistent with primary diffuse large B-cell lymphoma of the central nervous system. Use of adalimumab was discontinued. Following combination therapy with high-dose methotrexate and rituximab along with 20 sessions of cranial radiation therapy, the patient was disease-free at 14-month follow-up. CONCLUSIONS: We report the first case to our knowledge showing a possible association of central nervous lymphoma and adalimumab.

Multiple Cranial Dural and Pial Arteriovenous Fistulas with Occlusion of All After Embolization of Primary Superior Sagittal Sinus Dural Fistula.

BACKGROUND: We present a rare case of multiple intracranial arteriovenous fistulas (AVFs). A young female presented with headache and a left eyelid pulsatile swelling. CASE DESCRIPTION: Magnetic resonance imaging demonstrated numerous dilated cortical veins, along with a prominent left superior ophthalmic vein. A diagnostic cerebral angiogram revealed 5 distinct AVFs including 4 dural AVFs (dAVFs) and a pial AVF (pAVF). The largest dAVF was at the superior sagittal sinus. The others included bilateral ethmoidal, torcular, and a pAVF arising of the right pericallosal artery. She was treated by endovascular transarterial Onyx embolization. Only the superior sagittal sinus fistula was treated via middle meningeal artery feeders with complete occlusion. Immediate follow-up angiogram also showed complete spontaneous occlusion of the untreated dAVFs and pial AVF. CONCLUSIONS: This case is exceedingly unique considering the multiplicity of AVFs, concurrent presence of pial and dural AVF, and spontaneous occlusion of all untreated AVFs after embolizing the largest shunting fistula.

Subacromial Impingment Syndrome does not alter muscle onset activation patterns during shoulder cardinal movement at different speed and load.

This study examines neuromuscular firing patterns in healthy and subjects diagnosed with SIS of the periscapular, prime-moving, and rotator cuff muscles during "clinical" cardinal plane physiological movements at different speeds and loads. EMG recordings were taken in 34 healthy and 34 subjects diagnosed with Subacromial Impingement Syndrome (SIS) of the prime movers, periscapular, and rotator cuff muscles during flexion, scaption, and abduction performed at fast, medium, and slow speeds with a loaded (3 kg) and unloaded arm. Differences in firing patterns between groups were analyzed by fitting mixed linear models with random intercepts per subject, and fixed factors for group, muscle, movement type, speed, and load. No difference in timing of activation was seen between the healthy and SIS. Onset timing of prime movers, periscapular, and rotator cuff muscles were prior to movement in all scenarios studied, with rotator cuff muscles firing last. Speed and load appear to independently vary muscle activation timing in a non-intuitive manner in both healthy and SIS. The lack of different firing neuromuscular patterns in subjects diagnosed with SIS and healthy subjects raises the need to consider individual assessment of motor patterns rather than generalized patterns.

Rescue Maneuver for Dislocated Woven EndoBridge Device in Middle Cerebral Artery.

BACKGROUND: Intrasaccular flow disruption has emerged as a useful modality for treatment of wide-necked saccular aneurysm at vessel bifurcations. The Woven EndoBridge (WEB) device is one such device that has been evaluated in several series with excellent safety and good midterm efficacy. Bailout techniques to retrieve or reposition a dislocated WEB device are sparse and associated with significant risks. We describe a case of a dislocated WEB device that was repositioned with a microcatheter alone. METHODS: We describe a case of a WEB device that inadvertently detached in the parent vessel and the technique we used to reposition it. A number of bailout techniques are discussed with pros and cons associated with each maneuver. RESULTS: An unruptured middle cerebral artery (MCA) aneurysm was treated by endovascular embolization with a WEB device. The WEB was deployed within the aneurysm without incident. However, the device failed to detach. While attempting to resheath the device, it extruded out of the aneurysm and then inadvertently detached in the MCA. After many options were considered, a microcatheter alone was used to push the device back into the aneurysm. CONCLUSION: Caution should be exercised, especially when detaching the WEB device. Microcatheter repositioning by pushing the dislocated device may be attempted, especially if part of the device is within the aneurysm. This is the first description of the described microcatheter repositioning rescue maneuver.

Shoulder muscle onset timing during clinical assessment movements is the same in elite handball players as non-athletes: Implications for clinical assessment.

OBJECTIVES: This study examines neuromuscular firing patterns in overhead athletes and non-athletes of the periscapular, prime-moving, and rotator cuff muscles during "clinical" cardinal plane physiological movements. DESIGN: Cohort prospective study. SETTING: EMG recordings were taken of the periscapular, prime-moving, and rotator cuff muscles during flexion, scaption, and abduction performed at fast, medium, and slow speeds with a loaded (3 kg) and unloaded arm. PARTICIPANTS: 14 Handball players and 20 non-athletes. Differences in firing patterns between groups were analyzed by fitting mixed linear models with random intercepts per subject, and fixed factors for group, muscle, movement type, speed, and load. MAIN OUTCOME MEASURES: No difference in timing of activation was seen between the professional athletes and non-athletes. RESULTS: Speed and load appear to independently vary muscle activation timing in a non-intuitive manner in both athletes and non-athletes. Onset timing of periscapular, prime movers and rotator cuff muscles are prior to movement in all scenarios studied, with rotator cuff muscles firing last. CONCLUSIONS: Onset activation patterns in overhead athletes are not different to non-athletes during cardinal plane movements.

[Obstructive sleep apnoea syndrome]. / Síndrome de apneas-hipopneas durante el sueño.

INTRODUCTION: Obstructive sleep apnoea (OSA) is highly prevalent in children and a major public health problem. An attempt is made to determine the clinical and polysomnographic presentation of paediatric OSA in our area. PATIENTS AND METHODS: Retrospective descriptive study of sleep tests conducted on children up to 14 years-old from 1999 to 2012 in the Sleep Unit of the University Hospital of Albacete. Age, gender, anthropometric, clinical data, indication and variables of sleep study, treatment, and outcomes were collected. RESULTS: The study included 234 children. OSA was found in 71.8%, with 42.3% moderate and 44.6% severe. The majority were male (60.7%) and the mean age 5 was years, of whom 78% were pre-school or school age. There was overweight/obesity in 44%, with 93.4% snoring, apnoea 84.5%, and 5.4% daytime sleepiness. There were 23 polysomnographies and 145 polygraphies, with a median apnoea/hypopnoea index (AHI) of 10, Sat.O2 minimum 84%, desaturation index 8, and mean sleep supine 53.65% and supine events 57.61%. Treatment was lifestyle modifications 29.2%, CPAP 6%, and surgery 42.9%. Improved snoring and/or apnoea 69.4%, and weight 32.4% of overweight/obesity children. CONCLUSIONS: Most of the studied children had a pathological AHI. Almost half were overweight/obese, and a high percentage had moderate-severe OSA. Most frequent treatment was surgery. The clinical outcome was favourable in almost 70%. Less than a third with OSA and overweight/obesity improved weight.

Successful treatment of childhood intramedullary spinal cord astrocytomas with irinotecan and cisplatin.

Childhood spinal cord astrocytomas are rare diseases, and their management is controversial. We report here our successful experience using irinotecan and cisplatin in three consecutive infants with progressing intramedullary astrocytomas. The first patient was a 16-month-old girl who presented with a grade III intramedullary astrocytoma that rapidly progressed after surgery and adjuvant chemotherapy. Weekly irinotecan (50 mg/m(2)) and cisplatin (30 mg/m(2)) for four consecutive weeks (one cycle) for a total of four cycles (I/C regimen) was used in order to avoid or delay radiotherapy. Radiological complete remission was achieved 10 months after completion of therapy, and 3.5 years after diagnosis the patient remains disease free. The second patient was a 19-month-old boy with a C3-T4 grade II intramedullary astrocytoma who received up-front vincristine and carboplatin for two months but remained clinically symptomatic. A followup MRI showed a larger tumor, and the patient was switched to the I/C regimen. A marked clinical improvement occurred after the first cycle, and MRI showed a very good partial remission at the end of therapy. At 16 months after diagnosis, the patient remains disease free. The third patient was a 10-month-old girl with a C2-T3 grade II intramedullary astrocytoma. She presented with severe pain that became steroid dependent during the month she was treated with the vincristine-carboplatin regimen. When she was switched to the I/C regimen, the clinical symptoms responded within days. MRI at the end of therapy showed a significant reduction in tumor size, and one year after diagnosis the patient remains symptom free. Using this I/C regimen for childhood intramedullary astrocytoma, we obtained remarkable clinicoradiological responses while avoiding the use of radiotherapy.