Cylinder tumor surgery in pediatric low-grade gliomas.

BACKGROUND: Periventricular pediatric low-grade gliomas (pLGG) present a surgical challenge due to their deep-seated location, accessibility, and relationship with the subcortical network connections. Minimally invasive parafascicular approaches with tubular brain retractors (port brain surgery) have emerged, in recent years, as an alternative to conventional microsurgical and endoscopic approaches for removal of periventricular tumors. OBJECTIVES: To describe the minimally invasive approach with tubular brain retractors for periventricular pLGG, its technique, applications, safety, and efficacy. METHODS: In this article, we describe the port brain surgery techniques for periventricular pLGG as performed in different centers, with different commercialized tubular retractor systems. Illustrative cases followed by a literature review are analyzed, with a detailed description of different approaches or techniques, comparing their advantages and disadvantages with contemporary microsurgical and endoscopic approaches. CONCLUSIONS: The port brain surgery with micro-exoscopic vision and endoscopic assistance, for the treatment of deep-seated lesions such as periventricular pLGG, is an alternative for achieving a functionally safe-gross total or subtotal-tumor resection, obtaining adequate tissue for pathological examination. This technique could offer a new dimension for a less-invasive, safe, and effective access to deep-seated tumors, offering the possibility to lower morbidity in experienced hands.

Neurovascular stents in pediatric population.

PURPOSE: The purpose of the study is to analyze the results obtained using stents for the treatment of neurovascular diseases in pediatric patients. METHODS: A retrospective study of 6-year period was undertaken evaluating clinical charts and imaging studies of patients treated with stents because of neurovascular diseases. RESULTS: Nine patients were managed with 10 stents. Seven children were females. The median age was 11 years. There were four cases of broad neck cerebral aneurysms, a pseudoaneurysm of the cervical internal carotid artery, a vertebro-jugular fistula, two patients with internal carotid artery (ICA) stenosis affecting the cervical and supraclinoid segment, and a vertebral artery dissection. The only complication was a silent posterior communicating artery (PCoA) thrombosis in a PCoA aneurysm treated with two stents. Dual antiplatelet therapy was given after the procedure to avoid in stent thrombosis. CONCLUSION: Stents are safe and effective for treatment of neurovascular diseases in children, but studies are needed in order to protocolize the use of antiplatelet drugs in children.

Neurosurgical training with simulators: a novel neuroendoscopy model.

PURPOSE: The aim of this study is to present a novel neuroendoscopy simulation model in live animals, with the objective of enhancing patient safety with realistic surgical training. METHODS: A simulation model using live Wistar rats was designed after the approval of the Institutional Committee for the Care and Use of Laboratory Animals. Under anesthesia, a hydroperitoneum was created in order to simulate a cavity with mesenteric membranes and vessels, viscera, and a solid and bleeding tumor (the liver) floating in a liquid environment. For validation purposes, we evaluated trainees' basal and final skills for each neuroendoscopic procedure, and we also acknowledged trainees' and instructors' opinion on the model's realism. RESULTS: This model is simple and low cost effective for complete and real-life training in neuroendoscopy, with the possibility of performing all the basic and advanced endoscopic procedures, such as endoscopic exploration, membrane fenestration, vessel coagulation, hematoma evacuation, and endoscopic tumor biopsy and resection using a ventricular neuroendoscopy set. Although the model does not represent human ventricular anatomy, a reliable simulation is possible in real living tissue in a liquid environment. Trainees' skills improvements were notorious. CONCLUSION: Minimally invasive endoscopic techniques require specific training. Simulation training can improve and accelerate the learning curve. The presented training model allows simulating the different neuroendoscopic procedures. We believe that due to its practical possibilities, its simplicity, low cost, reproducibility, and reality, being live animal tissue, it can be considered a fundamental model within a complete training program on neuroendoscopy.

Intracranial pial fistulas in pediatric population. Clinical features and treatment modalities.

PURPOSE: The purpose of the study is to describe the clinical manifestations and treatment modalities of patients having intracranial pial arteriovenous fistulas (PAVFs). METHODS: We retrospectively analyzed the cases of PAVFs from January 2004 to December 2013. Medical charts, diagnostic images, surgical, and endovascular reports were reviewed retrospectively during each of the procedures and follow-up. We recorded patient demographics, clinical presentation, treatment modalities, and outcome. RESULTS: Ten patients with single PAVFs were identified, one of them with multiple holes. The median age was 7.5 years old (20 days to 14 years). Six patients were male (60% of cases). Four PAVFs were localized in the posterior fossa, and six were supratentorial (60%). Two patients had intracranial bleeding, three presented seizures, one was studied for chronic headaches, three manifested by growth retardation, one had hydrocephalus, and one had a congestive heart failure (CHF) and vein of Galen aneurysmal malformation (VGAM). The latter did not improve after embolization and died few days later. Endovascular therapy was used in eight, whereas two patients were surgically managed. Total occlusion of the fistula was achieved in all cases. CONCLUSIONS: PAVF affects pediatric population at different ages with miscellaneous clinical manifestations. Endovascular treatment is safe and effective when the venous side of the fistula can be occluded.

Supratentorial intraventricular solitary schwannoma. Case report and literature review.

OBJECTIVE: The objectives of this study were to present a case of a solitary intraventricular schwannoma with a review of the literature and to analyse the current theories of its origin. DESCRIPTION: A 16-year-old male patient, without any pathological, genetic or familial history of significance, presented with symptoms of intracranial hypertension and progressive left brachiocrural paresis. The magnetic resonance image showed a bulky intraventricular space-occupying lesion emerging from the posterior horn of the right lateral ventricle, with an irregular nodular component intimately connected to the choroid plexus, and a multiloculated cystic component extending beyond the ventricle. SURGICAL APPROACH: A right parietal craniotomy was performed, revealing a multiloculated cyst with xantochromic fluid and a soft brownish red nodule. The lesion was dissected surrounding the periphery and coagulating a vascular pedicle related to the wall of the right lateral ventricle and its choroid plexus. Total excision was achieved. The pathological exam reported an intraventricular schwannoma (WHO grade 1). The patient evolved favourably, with no recurrence at 36-month follow-up. CONCLUSION: The literature describes less than 45 cases of schwannomas not associated to cranial nerves of the following locations: intramedullary, leptomeningeal and only 12 intraventricular cases. The three theories explaining the origin of this last group describe: (1) a neoplastic transformation of peripheral nerve fibres, (2) a neoplastic transformation of autonomic neural tissue located within the intraventricular choroid plexus and (3) an abnormal embryogenesis leading to a failed migration of the neural crest cells. Complete resection is the therapeutic goal for this benign pathology to avoid recurrence.

Cerebral aneurysms in children: are we talking about a single pathological entity?

PURPOSE: The objective of this article is to highlight the fact that cerebral aneurysms in children are heterogeneous unlike in the adult population. MATERIAL AND METHODS: This is a retrospective review of 17 children with intracranial aneurysms who were managed at a single institution from 2004 to 2009. RESULTS: The median age was 12 years (range 10 months-17 years). Sixty-five percent of the aneurysms were saccular and 24% were fusiform. There was one infectious and one distal lenticulostriate aneurysm. Patients with saccular aneurysms were predominantly male and presented more commonly with intracranial hemorrhage (91%). The fusiform aneurysms were dissecting in nature or chronic with intramural thrombus and mass effect. The treatment was dependent upon the type and location of the aneurysm. CONCLUSION: Pedriatic aneurysms are a heterogeneous group of intracranial arterial diseases with different etiologies, diverse morphology, and dissimilar clinical manifestations.

[National Nursing Consensus on management of severe traumatic brain injury in children]. / Consenso Nacional de Enfermería sobre el manejo del niño con lesión cerebral por traumatismo de cráneo grave.

The nursing professional who treats critically ill children with cerebral injury is a key element within the pediatric intensive care team, since, through exhaustive assessment, plans nursing care in an integral manner aimed at the child and the family, and plays an essential role in the care of patients mainly at the hospital level (as well as at home). Therefore, the role played by nursing in the care of children with severe brain trauma is crucial. This guide offers nursing recommendations on neurocritical care, focusing on a systemic view based on nursing diagnoses according to the North American Nursing Diagnosis Association.

El profesional de enfermería que atiende a niños críticamente enfermos con lesión cerebral es un miembro clave dentro del equipo intensivista pediátrico, ya que, mediante la evaluación exhaustiva, planifica cuidados de enfermería de manera integral dirigidos al niño y a la familia. La enfermería como una profesión que entiende la salud de la persona humana desde una mirada integral cumple un rol esencial (indispensable) en el cuidado de los pacientes, principalmente, a nivel hospitalario (como domiciliario). Por ende, el rol que juega la enfermería en la atención de un niño con traumatismo encéfalocraneano grave es crucial en la gestión del cuidado infantil. Esta guía ofrece recomendaciones de enfermería sobre los cuidados neurocríticos focalizando una mirada sistémica basada en diagnósticos de enfermería según la Asociación Americana de Diagnósticos de Enfermería.

[Neurosurgical planning using osirix software]. / Planificación Neuroquirúrgica con Software Osirix.

INTRODUCTION: Anatomical individuality is key to reduce surgical trauma and obtain a better outcome. Nowadays, the advances in neuroimaging has allowed us to analyze this anatomical individuality and to plan the surgery. With this objective, we present our experience with the OsiriX software. TECHNICAL DESCRIPTION: We present three different applications as example of forty procedures performed. Case 1: Patient with a premotor cortex convexity parasagittal meningioma; Case 2: Patient with a nonfunctioning pituitary macroadenoma operated on 2 years ago in another institution, achieving a partial resection by a transsphenoidal approach; Case 3: Patient with bilateral middle cerebellar peduncles lesions. OsiriX Software was used for surgical planning. Volumetric CT and MRI images were fused and 3D reconstruction images obtained, to analyze anatomical relationships, measure distances, coordinates and trajectories, among other features. DISCUSSION: OsiriX software is a useful, open-source and free software tool that provides the surgeon with valuable information. It allows to study individual patient's anatomy and plan a surgical approach in a fast, simple, inexpensive and safety way. In Case 1 the software let us analyze the relationship of the tumor with the surrounding structures in order to minimize the approach's morbidity. In Case 2, to understand the unique anatomic characteristics of an already operated patient giving us important information regarding pathways and need for extra bone removal, achieving a complete tumor resection by an endoscopic transnasal approach. In Case 3, allowed us to obtain the stereotactic coordinates and trajectory for a not visualizable CT scan lesion. CONCLUSION: When expensive neuronavigation systems are not available, OsiriX is an alternative for neurosurgical planning, with the aim of reducing trauma and surgical morbidity.

Planificación neuroquirúrgica con software osirix. presentación de 3 casos y descripción de la técnica utilizada / Neurosurgical planning with osirix software. presentation of 3 cases and description of the technique used

Objetivo: conocer la individualidad anatómica es clave para reducir el trauma quirúrgico y obtener un mejor resultado. Actualmente, el avance en las neuroimágenes ha objetivado esa individualidad anatómica, permitiendo planificar la intervención quirúrgica. Con este objetivo, presentamos nuestra experiencia con el software Osirix. Descripción de la técnica: se presentan 3 casos ejemplificadores. Caso 1: paciente con meningioma de la convexidad parasagital izquierda en área premotora; Caso 2: paciente con macroadenoma hipofisario, operada previamente por vía transeptoesfenoidal en otra institución con una resección parcial; Caso 3: paciente con lesiones bilaterales en pedúnculos cerebelosos medios. Se realizó la planificación prequirúrgica con el software OsiriX, fusionando y reconstruyendo en 3D las imágenes de TC e IRM, para analizar relaciones anatómicas, medir distancias, coordenadas y trayectorias, entre otras funciones. Discusión: el software OsiriX de acceso libre y gratuito permite al cirujano, mediante la fusión y reconstrucción en 3D de imágenes, analizar la anatomía individual del paciente y planificar de forma rápida, simple, segura y económica cirugías de alta complejidad. En el Caso 1 se pudieron analizar las relaciones del tumor con las estructuras adyacentes para minimizar el abordaje. En el Caso 2, el software permitió comprender la anatomía post-operatoria previa del paciente, para determinar la trayectoria del abordaje transnasal endoscópico y la necesidad de ampliar su exposición, logrando la resección tumoral completa. En el Caso 3 permitió obtener las coordenadas estereotáxicas y trayectoria de una lesión sin representación tomográfica. Conclusión: en caso de no contar con costosos sistemas de neuronavegación o estereotáxia, el software OsiriX es una alternativa a la hora de planificar la cirugía, con el objetivo de disminuir el trauma y la morbilidad operatorias.

Introduction: understanding of the anatomical individuality is key to reduce surgical trauma and obtain a better outcome. Nowadays, advances in neuroimages allows to analyze this anatomical individuality and so planning surgery. With this objective, we present our experience with the OsiriX software. Technical description: we present three different applications as examples. Case 1: patient with a premotor cortex convexity parasagittal meningioma; Case 2: patient with a nonfunctioning pituitary macroadenoma operated on 2 years ago in another institution, with partial resection by transsphenoidal approach; Case 3: patient with bilateral middle cerebellar peduncles lesions. OsiriX Software was used for surgical planning. Volumetric CT and MRI images were fused and 3D reconstruction images obtained, to analyze anatomical relationships, measure distances, coordinates and trajectories, among other features.Discussion: OsiriX software is a useful, open-source and free software tool that provides surgeons with valuable informations. It allows to study individual patient’s anatomy and plan a surgical approach in a fast, simple, economic and safe way. In Case 1 the software let us analyze the relationship of the tumor with the surrounding structures in order to minimize the approach’s morbidity. In Case 2, to understand the unique anatomic characteristics of an previously operated patient giving us important information regarding pathways and need for extra bone removal, achieving a complete tumor resection by an endoscopic transnasal approach. In Case 3, allowed us to obtain the stereotactic coordinates and trajectory for a not visualizable CT scan lesion.Conclusion: when expensive neuronavigation systems are not available, OsiriX is an alternative for neurosurgical planning, with the aim of reducing trauma and surgical morbidity.

Fistulas piales cerebrales en pediatría / Pial shunts in pediatric patients

Objective: to analyze our experience in brain pial arteriovenous fistulae in paediatric patients and review the modern concepts about this pathology.Materials and method: between 2004 and 2011, 6 cases of pial arteriovenous fistulae were diagnosed and treated at the National Hospital of paediatrics “Juan P.Garrahan”, defining them as arteriovenous malformations with one or more arterial connections with one single venous drainage, without interposed nidus. We reviewed the medical records and neuroimaging. The main method for diagnosis was cerebral angiography. Results: there were 4 male and 2 female patients, ages ranging from 1 month to 14 years old. 3patients presented brain hemorrhage, 2 had seizures as the initial symptom, and one was diagnosed because of his congenital hydrocephalus. 2 were treated with open surgery and 4 with embolisation. There were no important complications or rebleeding. Conclusion: brain pial fistulas are infrequent vascular malformations important for their high risk of bleeding and relative frequency in paediatrics. The management of these patients needs a multidisciplinary team for analysis, discussion, choosing the most suitable treatment, and follow up.

Tratamiento temprano de la cuadriparesia espástica y distonia severa con bombas infusión intratecal de flujo fijo / Spastic tetraparesis and severe dystonia treatment with intratechal fixed-flow bombs

Objective: to establish that the implantation of smaller fixed rate intrathecal infusion pumps is the best choice for the early treatment of severe spastic quadriparesis and dystonia and to determine its optimal placementMaterials and method: seven patients were implanted with fixed rate pumps. In two patients the indication was chronic pain and were excluded from the present study. Three patients were operated with 5.6 centimeters of diameter Tricumed pumps and two patients with Codman Arquimedes pumps. Results: two patients implanted with tricumed pumps and two with codman pump evolved favorably up to date, with a refill of 190, 200, 232 and 245 micrograms respectively. The device had to be explanted from the last patient due to post-op infection and dysfunction. Conclusion: early implantation of a baclofen pump facilitates and simplifies neuro-orthopedic treatments and gastrostomy implants. With an adequate subfascial technique and smaller infusion pumps satisfactory results can be achieved.

Aneurismas cerebrales en la infancia: un solo nombre para diferentes enfermedades / Cerebral aneurysms in infancy: a name for different diseases

Objetivo. Resaltar la heterogeneidad de los aneurismas cerebrales en la población pediátrica. Material y método. 19 pacientes con 20 aneurismas intracraneanos fueron tratados en nuestro Hospital en los ultimos 6 años.Resultados. La edad media fue de 12 años (rango 10 meses a 17 años). 65 %de los aneurismas fueron saculares, 25% fusiformes, hubo un aneurisma infeccioso y otro lenticuloestriado distal. Los pacientes con aneurismas saculares fueron predominantemente varones y se manifestaron más comúnmente con hemorragia intracraneana (92%). Los aneurismas fusiformes se originaron posteriormente a una disección o fueron crónicos con trombo mural y ejerciendo efecto de masa. La terapéutica fue diferente según el tipo aneurismático. Conclusión. Los aneurismas pediátricos son un grupo heterogéneo de enfermedades arteriales intracraneanas con manifestaciones clínicas, morfología y terapéutica diferentes.

Neuroendoscopia guiada por neuronavegación / Neuroendoscopy guided by neuronavigation

Objetivo. Describir y analizar una serie de pacientes en los que se utilizó neuroendoscopía guiada por neuronavegación para la resolución de diferentes patologías neuroquirúrgicas. Material y método. Se realizó una análisis retrospectivo de las historias clínicas de los pacientes en los que se combinaron la utilización del neuroendoscopio de óptica rígida de 0° o 30° STORZ-RECQ y de los neuronavegadores (BRAIN LAB Vectorvisión II ó Electra). Resultados. Desde abril de 2001 hasta diciembre de 2006, operamos 14 pacientes combinando ambas tecnologías. Las edades de los pacientes fueron de entre 10 meses y 10 años (promedio 7.5 años). Las patologías que motivaron la cirugía fueron: seis quistes aracnoideos próximos a ó dentro de ventrículos pequeños, cuatro tumores hipotalámicos, tres ventrículos excluidos y una cavidad porencefálica. La precisión del procedimiento de neuronavegación fue siempre inferiora 1mm, sin embargo no pudimos acceder al sistema ventricular en uno de los catorce pacientes. En los trece restantes se logró el planeamiento prequirúrgico en forma adecuada. Conclusión. La neuroendoscopia guiada por estereotaxia sin marco con neuronavegador es una técnica precisa y segura cuando la patología es solucionable endoscópicamente y los ventrículos son pequeños.

Enfermedad de Moya Moya / Moya Moya disease

Introducción.La enfermedad de Moya Moya(EM)es una vasculopatía oclusiva cerebral progresiva cuyo diagnóstico se realiza por arteriografía digital.Material y Métodos:Evaluación retrospectiva de las historias clínicas de cuatro mujeres y un varón con diagnóstico de EM evaluados en 1987-1996.Resultados:En cuatro niños se inició con episodios de hemiparesia transitoria en uno,con convulsiones parciales a una edad promedio de 2,5 años(rango 1-6 años).Los estudios tomográficos mostraron imágenes hipodensas compatibles con accidente cerebrovascular isquémico.La arteriografía mostró en todos los pacientes imágenes características de EM.Cuatro pacientes tuvieron un seguimiento promedio de 4,2 años(r:2 y 9 años).Todos padecen un severo compromiso motor,tres retardo mental y uno epilepsia de difícil control.A dos pacientes se les realizó tratamiento quirúrgico(encefalodurosinangiosis),falleciendo uno en el posoperatorio inmediato y el restante no reiteró episodios isquémicos en un lapso de observación de 2 años.Conclusiones:La evolución natural de la EM es progresiva,con deterioro neurológico debido a repetidos episodios isquémicos.Actualmente,el tratamiento quirúrgico sería el más apropiado.Sería conveniente que un equipo multidisciplinario evalúe el momento y método terapéutico adecuado

Use of ultrasonic aspiration for dural opening in re-do epilepsy surgery: a preliminary report

Dural detachment from the brain in cranial reoperations has been accomplished previously by selective coagulation and cutting of brain cutting procedures led the authors ultrasonic aspiration during tumor surgery or brain cutting procedures led the authors to speculate that detachment of the duramater from the brain tumors by appling the Cavitron ultrasonic surgical aspirator (CUSA) to the brain-duramater interface could be used to reduce bleeding and facilitate dural opening during cranial re-operations. Thus, the use of ultrasonic aspiration and its effects on brain separation from the duramater were examined. Ten patients underwent a second craniotomy for epilepsy surgery (5 cases of extended temporal lobectomy and 5 cases of extended extratemporal lesionectomy). Intraoperative use of the CUSA during dural opening produced immediate blanching of the duramater and enhanced visualization of the cortical surface without distortion of the brain anatomy. Incremental dural opening and brain visualization is achieved by careful application of ultrasonic aspiration directly into the brain-dura limit, producing immediate regional dural devascularization. Use of this technique reduces cortical and dural bleeding and enhances the ease and effectiveness of brain visualization

Diferentes tecnicas neuroendoscopicas para el tratamiento de la hidrocefalia en pediatria. Estudio multicentrico en 360 pacientes / Different neuroendoscopical Techniques for the treatment of pediatric hydrocephalus Study in 360 patients

Objective: To analize our experience in the endoscopical treatment of pediatrichydrocephalus. Methods: In a retrospective study we analyzed 360 hidrocephalic patients treated endoscopically in 5 Pediatric Neurosurgical Services in Buenos Aires. 374 procedures were performed: 207 third-ventriculostomies, 70 septal fenestrations, 48 catheter implantations, 26 cyst-ventriculostomies, 11 septomies, 7 catheter removals, 4 aqueductoplasties and 1 monoplasty. Results: Third ventriculostomy was the most frequent procedure with a very low failure rate (19,8 por ciento). The overall complication rate was 4,5 por ciento. IN pineal tumor related hydrocephalus, a simultaneous biopsy procedure was always sucessful. Conclusions: Endoscopic treatment of hydrocephalus must always be consideraded as an effective method and as the first choice treatment in an important number of patients