[Evaluation of the results of surgery of intracranial supratentorial tumors in 363 children over the past 50 years (1948-1997)]. / Zhodnocení výsledku u 363 detí operovaných pro nitrolebecní supratentoriální nádory za 50 let (1948-1997).

At the Department of Neurosurgery, Hradec Králové, in the course of 50 years (1948-1997) 363 children, 199 boys and 164 girls (1.2:1) aged under 18 years were operated on for intracranial supratentorial tumours. The average age in children at the time of first operation was 9.3 years; most frequently they participated those of 8 and 11 to 14 years of age. Children aged 1, 2 and 3 years constituted 4.7%, 4.4% and 5% of operations. The tumours were located in: cerebral hemispheres 123 (33.8%), lateral ventricles 17 (4.7%), IIIrd ventricle 5 (1.4%), hypothalamus 26 (7.2%), thalamus 19 (5.2%), basal ganglia 24 (6.6%), sellar region 86 (23.7%), chiasmatic region 38 (10.5%) and pineal region 19 (5.2%). 223 of tumours (61.4%) were located in the midline and 140 of them (38.6%) laterally (in hemispheres and lateral ventricles of the brain). 268 of tumours were histologically verified (73.8%) and 95 of cases were evaluated according to the neurosurgeon's point of view and/or to the clinical and CT controls (26.2%), because of the biopsy (especially in the pre-CT era) was highly riskfull. Histological typing of tumours was retrospectively reevaluated according to the present WHO classification. Summarized 53 types of tumours were differentiated. The most frequent lesions were various variants of astrocytic gliomas (135 = 37.2%). Further on the craniopharyngiomas dominated (73 = 20.1%). The tumours were operated on through craniotomies 299 times, by primarily drainage operations 52 times, functions 6 times, stereotactically 8 times and or by combination of these operations 82 times. Reoperation was needed for postoperative complications in 1.7% (6 times) and for delayed recurrence in 11.3% (41 times). The postoperative mortality (up to 1 month after initial surgery) was in 156 children operated on in pre-CT era (between 1948 and 1977), as compared with 207 children operated on in the era of CT (between 1978 and 1997) in astrocytomas 3.8:0%, pilocytic astrocytomas 6.5:2.8%, craniopharyngiomas 15.4:0% and in all tumours 12.2:2.9%. 16 children with orbital tumours (the average age 5.8 years) operated on with orbitofrontal approach were also evaluated. 14 of them survive for 5-37 years (on the average 16.6 years). The chronological development of diagnostic and operative processes of supratentorial tumours in children's care is discussed. The prognostic elements of present histobiological classification of tumours are positively evaluated.

Posterior cranial fossa surgery in 454 children. Comparison of results obtained in pre-CT and CT era and after various types of management of dura mater.

At the Department of Neurosurgery, Hradec Kralové, 454 children (aged under 18 years) were operated on for posterior cranial fossa lesions in a period of 49 years (1948-1996). The majority (402) had tumours: cerebellar astrocytomas 149 (37.1%), medulloblastomas 139 (34.6%), brain stem gliomas 46 (11.4%), ependymomas 28 (7.0%), and others 40 (9.9%). Postoperative mortality was compared for the pre-CT era (1948-1977) and the CT era (1978-1996): astrocytomas (8.6%:4.7%), medulloblastomas (14.9%:2.9%), brain stem gliomas (21.7%:19.0%), ependymomas (18.2%:6.3%), and others (40.0%:7.4%). The initially high mortality was due to insufficient intracranial decompression, brain oedema and disturbances of cerebrospinal fluid circulation. Obstructive hydrocephalus was treated in 53 children with tumours and 25 with aqueduct stenoses, by Torkildsen's drainage in 5.5%, and/or by catheterisation of aqueduct in 12.3%. The main postoperative complications of medial posterior fossa surgery in 429 children operated on were: pseudomeningocele (12.3%), active hydrocephalus (6.2%) and CSF leakage (4.6%). Only 8.2% had shunts placed for these complications. We presume that this low percentage of shunts used results from a frequent use of duraplasties and drains installed at the primary operation. The dura mater was initially (1948-1954) left open (50 cases), and later (1955-1958) also sutured (37 cases), and from 1958, onward, and especially from 1961, reconstructed by a medial approach by means of various grafts (377 cases). In all, duraplasty was performed in 81.6% of cases. The grafts used for dura mater reconstruction were prepared from autogeneic (1.6%), allogeneic (72.3%), xenogeneic (24.8%), or synthetic (1.3%) material. They were successful in 99.2% of cases (all materials). Our own suture technique for posterior fossa duraplasty is presented.

Choroid plexus cyst of the left lateral ventricle with intermittent blockage of the foramen of Monro, and initial invagination into the III ventricle in a child.

A cyst of the choroid plexus of the left lateral ventricle with intermittent blockage of the foramen of Monro and initially with invagination of the III ventricle in a child is described. In a 6-week-old boy a ventriculoatrial shunt was implanted for correction of an active asymmetrical hydrocephalus of unknown origin. When he was 3 months of age a water-soluble contrast CT ventriculography revealed a noncolloid cyst localised predominantly in the upper portion of the III ventricle. At that time the ventricular catheter obstructed with choroid plexus was removed; new bilateral catheters in a parieto-occipital region were implanted. In the course of the next 4 years, first the atrial catheter had to be extracted and then the peritoneal catheter was changed, in both cases because of obstruction. Periods of normal life alternated with periods of transient and intermittent symptoms of increased intracranial pressure, papilloedema, and myoclonic jerks. Repeated computed tomography (CT) and magnetic resonance imaging (MRI) showed stabilised hydrocephalus with an enlarged left lateral ventricle. When the boy was 16 years old MRI revealed a choroid plexus cyst in the left lateral ventricle 2 cm in diameter, with a ballvalve type of obstruction of the foramen of Monro. CT stereoendoscopic resection of the wall of a large cyst filled with cerebrospinal fluid was performed, and two additional adnexal small cysts were coagulated using the bipolar coagulator, Diomed 25 laser and scissors; the symptoms then regressed, except for superior bilateral altitudinal anopsia. Light and electron microscopy of the cyst wall is reported. The cyst was composed of collagenic connective tissue lined with a basal lamina lacking in epithelial cells. The preoperative and postoperative MRI are presented. Choroid plexus cysts localised in the anterior part of lateral ventricles are very rare, and all reported cases have been in male patients. According to the literature our case is only the third ever described in a child.

Detailed evaluation of 2959 allogeneic and xenogeneic dense connective tissue grafts (fascia lata, pericardium, and dura mater) used in the course of 20 years for duraplasty in neurosurgery.

Surgical experience with 2959 allogeneic and xenogeneic dense connective tissue grafts (1767 of fascia lata, 909 of pericardium, and 283 of dura mater), used in 2665 neurosurgical operations performed in the course of 20 years (1976 to 1995) is reported. Duraplasty using either allogeneic or xenogeneic grafts has had a similar, and favourable clinical outcome. Nevertheless, the pliable deep frozen fascia lata grafts, which could be used in any location, have been reserved for sella turcica plugging, anterior cranial base plasty, aneurysmal wrapping, and surgery of lipomyelomeningocele. Pericardium and dura mater grafts were in the majority of cases used over the brain convexity and posterior cranial fossa. Ovine pericardium proved to be superior to bovine and allogeneic pericardia because of its workability, flexibility, reduced thickness, and better transparency. Postsurgical complications occurred in 7.3%, and they were: 1) cerebrospinal fluid fistulas in 2.8%; 2) meningites in 2.3% (aseptic 1.4%, bacterial 0.8%, and tumoural 0.1% meningites); 3) pseudomeningoceles in 2.2%; 4) wound infections in 0.6%; 5) malresorptive hydrocephalus in 0.5%; and 6) adhesions to nerve tissue in 0.5%. The majority of complications healed without surgery. Forty-eight grafts (1.6%) failed to fulfil the requirements of the surgeon, and 46 of them were re-operated upon. Though another thirty-nine grafts healed successfully, 39 shunts (1.5%) had to be performed for malresorptive hydrocephalus (0.9%), and/or for a big pseudomeningocele (0.6%). So, the pure complication rate in 2665 duraplasties was 3.1%. The complex evaluation of the allogeneic and xenogeneic grafts (fascia, pericardium, and dura mater), used for duraplasty in neurosurgery during the last 20 years proved them, as remarkably good, with a success rates of 96.9%.

Ovine pericardium: a new material for duraplasty.

The authors report on their 2 1/2-year clinical experience using a dural substitute, ovine pericardium, stabilized with 0.3% glutaraldehyde, flat freeze-dried, and sterilized with gamma-irradiation. Packaging of the ovine pericardium in double-plastic transparent bags allows simple storage in operating rooms and the opportunity for the surgeon to choose an ideal graft according to its shape, size, and plasticity. The ovine pericardia were examined histologically and by transmission and scanning electron microscopy in their native, freeze-dried, and irradiated forms. The final product is composed solely of pericardium fibrosum interwoven with artificially formed extracellular microcavities that serve as natural pores for the ingrowth of host tissue. The surfaces of the grafts appear smooth on the inner and rough on the outer sides. Sixteen grafts were examined macroscopically at autopsy and four of these were also examined histologically to illustrate their successful healing with no adhesion to the underlying brain. As a new dural substitute, ovine pericardium proved to be superior to bovine and allogeneic pericardia because of its workability, flexibility, and reduced thickness. In a study of 120 grafts, all but one healed without complications.

Allogeneic cartilage used for skull base plasty in children with primary intranasal encephalomeningocele associated with cerebrospinal fluid rhinorrhea.

Three children with primary intranasal encephalomeningocele associated with cerebrospinal fluid rhinorrhea were operated on at the Department of Neurosurgery, Hradec Králové. In two children, aged 4 and 9.5 years, freeze-dried allogeneic costal cartilage was glued into the skull base defect. This plugging was covered up with deep frozen allogeneic fascia lata. In the third child, an only 1-year-old boy, after transection of the neck of the encephalomeningocele freeze-dried allogeneic dura mater was glued on extradurally and deep-frozen allogeneic fascia lata applied intradurally. The cerebrospinal fluid rhinorrhea ceased immediately after surgery. Spontaneous atrophy of the intranasal portion of the encephalomeningocele was demonstrated respectively 11, 1, and 7 years postoperatively on computed tomography. To evaluate cartilage healing histologically, the extracted allogeneic cartilage used for orbital roof plasty after 4 months was examined. The extent of spotty regressions represented about 7% of the tissue volume. It is stressed that, once diagnosed, intranasal encephalomeningocele associated with cerebrospinal fluid rhinorrhea should be operated on for prevention of meningitis as soon as possible.

Impedance monitoring in the stereotactic localization of intracranial structures.

Measurement of tissue impedance is a simple objective method for the localization of intracranial structures. Continuous bipolar impedance monitoring was performed during various CT-guided stereotactic procedures in 36 patients with brain pathology. The obtained values of the impedance profile along the trajectory were compared with the tissue density on CT scans or angled coronal and sagital CT reconstructions intraoperatively. The main goal was the selection of optimal biopsy targets and safe probe trajectory. Histologic findings of serial transtumoral biopsy were retrospectively correlated with both CT (or MRI) transposed data and patterns of tissue impedance. Intraoperative impedance monitoring enhanced the accuracy and safety of CT-guided procedures. The histologic examination of representative tissue samples avoids the risks of "blind" surgical or radiation management. This technique is reported with 6 illustrative cases.

Epilepsy associated with low-grade brain glial neoplasms.

In 1991-1993, 52 patients underwent surgery for low-grade supratentorial glioma. In 37 of them (astrocytoma 22, oligodentrocytoma 12, oligodendroglioma 2) seizures, often refractory to drug therapy, appeared as the first symptom. These cases were retrospectively analyzed. The patients had partial seizures: simple, complex, or secondarily generalized (preoperative duration: from 3 days to 17 years (mean 2 years); frequency: between 1 and 2/year and over 10/day). Neurological examination either revealed slight focal changes or was normal. Conventional craniotomy and resection of a tumor, without intraoperative electrocorticography, was performed. Partial resection was performed in 73%, subtotal in 5%, "total" in 22% of the cases. Postoperatively, 27 patients had focal radiotherapy, 3 of them in combination with chemotherapy. Two patients were reoperated. Out of 33 alive (89%), about two-thirds appear normal by neurological examination and are seizure-free at present (mean follow-up period 28 months). Most remain on antiepileptic drugs at lower doses. Histological and immunohistochemical analyses of resected tissue together suggest that the peripheral zone of cortical tumor infiltration may participate on epileptogenesis.

Posterior fossa duraplasty in children: remarks on surgery and clinical and CT follow-up.

A series of 314 posterior fossa duraplasties in children were performed at the Department of Neurosurgery, Hradec Králové, over the past 33 years. Computed tomographic (CT) imaging was used to compare the healing of various kinds of collagenic dural substitutes--allogeneic fascia lata, allogeneic dura mater and xenogeneic pericardium. Early (8 days to 3 months following surgery) and late (1-18 years following surgery) axial CT scans with sagittal reconstruction for duraplasty in 55 children were evaluated. In early postoperative CT scans, epidural collections of cerebrospinal fluid, sanguinolent liquid or haematoma and/or pseudocysts or pseudomeningoceles appeared. In late CT follow-up, calcifications and ossifications in the "suboccipital coverings complex" (SCC) gradually developed and pseudocysts or pseudomeningoceles rarely persisted. It is concluded, on the basis of perioperative, clinical, and CT examinations, that posterior fossa duraplasties in children formed an important anatomical barrier and regardless of the type of graft had a favourable outcome; CT was shown to be a suitable method for the demonstration of dural grafts at the site of craniectomies.

Catheterobronchial fistula due to vena cava superior thrombosis as a late complication of ventriculoatrial shunt.

A case of a catheterobronchial fistula as a rare late complication of a ventriculoatrial shunt is reported. The ventriculoatrial shunt was implanted in a 4-month-old boy suffering from extreme postinfectious hydrocephalus. During the following years, twelfth nerve palsy on the right, vertebralgias, and salty taste sensations in the mouth associated with intermittent coughing and swelling of the neck and supraclavicular region on the right side developed. Valvography established a diagnosis of fistula 12 years after the implantation of a shunt. Ultrasonography of the neck and mediastinum and contrast-enhanced dynamic computed tomographic scanning demonstrated a catheterobronchial fistula to the subsegmental bronchus of the anterior segment of the right upper lung lobe, a thrombosis of the right internal jugular and both right and left brachiocephalic veins and the superior vena cava, and an extensive collateral venous system mainly draining into the azygos vein. Normalization of cerebrospinal fluid and blood flow and pressure allowed extraction of the "atrial" catheter without complications. One year after surgery the boys is in good health and without signs of shunt dependence.

Mature sacrococcygeal teratoma containing the lower half of a human body.

Twins were diagnosed by ultrasound in a 29-year-old woman. The cesarean delivery revealed at first a mature girl with a large benign sacrococcygeal teratoma and then a healthy boy. X-ray and CT examinations of the teratoma showed pelvic and lower limb bones. A mature teratoma-tridermoma (weight 475 g) containing the underdeveloped lower half of a human body was confirmed during surgery and verified morphologically. The fraternal twins, i.e., the girl operated upon and her brother, have been followed for 5 years and are without any complaints. They have normal neurological function.

Benign cyst of the paramedian pontine tegmentum.

A benign ovoid cyst, without an epithelial lining, localized in the paramedian pontine tegmentum, was examined by computed tomography (CT) and magnetic resonance imaging (MRI) (25 x 15 x 15 mm) and successfully operated upon. The one-and-a-half syndrome (horizontal gaze palsy to the right and paralysis of adduction of the right eye) and ipsilateral "peripheral" VII nerve palsy dominated the clinical picture. Fenestration, 5 mm in diameter, of the cyst wall through the floor of the IV ventricle was performed and 2.6 ml of clear, colorless fluid was evacuated. Inspection of the cyst, using the operating microscope, revealed a smooth, white, glistening cavity with no evidence of other pathological tissue. Duraplasty was performed with allogenic pericardium. Neurological symptoms improved immediately after surgery. Light and electron microscopy of the cyst wall revealed a fibrillar astroglial network and fragments of ependyma at the ventricular side of the biopsy.

[A sedimentation chamber for cytological examination of cerebrospinal fluid]. / Sedimentacní komurka k cytologickému vysetrení mozkomísního moku.

A new advice for spontaneous sedimentation of cellular elements of body fluids as based on the J. Sayk principle is described. Gravitation force is applied which is deduced with graduated load onto the approximately constant and measured pressure of contact surface between the sedimentation pipe, paper and preparation glass. The advice is made of stainless steel, and its relatively simple construction allows easy manipulation, maintenance and reproducibility of results.

[External lumbar cerebrospinal fluid drainage with controlled flow-- its use in pediatric neurosurgery]. / Zevní lumbální likvorová drenáz s regulovaným prutokem--její vyuzití v detské neurochirurgii.

The authors describe cases of external lumbar CSF drainage with a regulated flow inserted lumbally or in the pseudomeningocele in children. During flow regulation during operation they were guided by the finding in the surgical field, during therapeutic use (in the course of 1-8 days) by setting the CSF output at 15 ml/hour. Drainage was used in extradural approach to the orbit, for treatment of liquorrhoea in surgical wounds of the posterior fossa, frontal and temporal drainage to clear the CSF in meningitis and to make inner drainage possible. CSF fistulae healed even after major craniectomies and infections due to the resistance of allogenic and xenogenic dural transplants. For external CSF drainage the authors used lumbar needles, intravenous Portex kits or original Cordis kits. The latter proved to be the best.

Congenital dermoid cysts over the anterior fontanel. Report on 13 cases in Czechoslovak children.

The authors report on 13 cases of dermoid cysts over the anterior fontanelle in Czechoslovak children. These children were 2-19 months of age; with a male-to-female ratio of 2:1. The cyst sizes ranged from 10 to 30 mm. Hence, the number of cases published in the world so far in children has increased to 174. Simultaneously, the number of European cases has increased to 30 (17.2%). Nevertheless, the dominance of the reported cases is still 74 in America (42.5%) and 45 in Africa (25.9%).

Bobble-head doll syndrome associated with the III ventricular cyst. Three cases in children 7 years after CVP or CVA shunting.

Thirty-nine cases of the bobble-head doll syndrome have been operated upon and are described in the literature. The authors re-evaluate three cases of III ventricle cysts treated with cystoventriculoperitoneal (CVP) or cystoventriculoatrial (CVA) shunting 7 years ago. In the first case (a 4.5-year-old girl), the CVP shunt was removed after 16 months due to suppuration around the device after trauma of the scalp. Nevertheless, the communication between the ventricle and cyst continued and the bobbing never returned. In the second case (a 10-year-old girl), after 4.5 years a pseudocyst at the end of the peritoneal catheter was accidentally found. It was evacuated and, as in the third case (a 17-year-old boy) follow-up for 7 years showed excellent results from the clinical point of view and CT scans.

[Repair of the dura mater in children using xenogenic pericardium]. / Plastika tvrdé pleny mozkové xenogennim perikardem u detí.

The authors report their five-year experience with the use of xenogenic calf pericardium for plastic operations of the cerebral and spinal dura mater which they introduced into neurosurgical practice in 1983. Of 165 grafts they selected 50 which they used in children for the plastic operation of the dura mater above the posterior cranial fossa, above the convexity of the brain and at the skull base. The xenogenic pericardium proved successful and resolved also the shortage of allogenic collagenous tissues (fascia lata, dura mater) used for plastic operations of the dura mater. Moreover, due to its resistance it achieved priority in some indications and localizations. When used, certain conditions must be met to ensure satisfactory incorporation (suitable size, intradural submersion, careful suture).

[Developmental cysts in the area of the quadrigeminal plate in children]. / Vývojové cysty v oblasti ctverohrbolí u detí.

The authors describe three cases of operated developmental cysts in the area of the laminae quadrigeminae in children. The performed multiple fenestrations or excision of the wall of the cyst and effective communication with the subarachnoid or ventricular system, as well as a plastic operation of the dura mater with collagen tissue from a Tissue bank. By means of light microscopy the walls of two cysts were examined (one arachnoid and one glioependymal), one cyst was examined by electron microscopy (glioependymal). The authors supplemented by their own cases the number of hitherto described cysts in the collicular region to 56.