Stainless steel mesh-acrylic cranioplasty.

Twenty-four steel mesh-acrylic plates have been used for repair of skull defects in 1970-73. Three plates had to be removed due to complications, two due to infection and one due to an allergic reaction. The plate is easy to mould, strong, and light. The cosmetic results are excellent.

[Medulloblastoma in children. A 20-year case load]. / Medulloblastom hos barn. Et 20 års materiale.

Between 1968 and 1987, seventy children below the age of 14 years were treated at one institution for cerebellar medulloblastoma. There were 41 boys and 29 girls. The 70 children included one pair of siblings. All the children have been followed up by one of the authors. During the first ten years, postoperative mortality within the first month was 17.5%. During the last ten years there was only one such death (3.5%). All children from the first ten-year period are dead. In the last ten-year period 25 of 35 children have survived (observation time 1-12 years, mean six years). This improvement is due to better surgical care and the use of post-operative irradiation and chemotherapy. Cerebral computerized tomography and magnetic imaging tomography are the investigational methods of choice for medulloblastoma today.

Fatal cardiopulmonary complications in children treated with ventriculoatrial shunts.

During the years from 1965 to 1986, 716 children underwent a total of 2065 shunt procedures in our department. Of these, 1298 were ventriculoatrial (VA). Until 1979, Pudenz VA shunts were almost exclusively used as the primary procedure as well as in revisions. Since 1980, mini-Holter VA shunts have been implanted as a second choice, usually in cases with repeated distal failure in ventriculoperitoneal (VP) shunts. Observation time for children with VA shunts is therefore from 10 to 23 years for the great majority. The cumulative death rate for all patients is 24% (175/716), 9% (64/716) being tumor patients who eventually died as a result of their neoplasm. Most of the other deaths were caused by shunt infection or occurred in a group of children where shunts had been implanted for palliative reasons and where follow-up was only sporadic. Among the 450 children with VA shunts, 15 fatal complications occurred that were directly related to the atrial catheter, resulting in an accumulated incidence of 3% of such serious side effects from VA shunting. Three of these 15 fatal cases presented with nonspecific signs of cardiopulmonary failure following 10-21 years' shunting, and they died from irreversible pulmonary hypertension within a few months. A fourth case of late cor pulmonale has done unexpectedly well and has improved considerably while receiving anticoagulant therapy for over a period of 3 years.

Shunt failure caused by valve collapse.

Shunt failure due to collapse of the Mini-Holter valve was observed 13 times in 11 out of 179 children with an implanted Mini-Holter ventriculo-peritoneal (VP) or ventriculo-atrial (VA) shunt during a 10 year period. Intussusception of the proximal or distal end of the valve thus caused a shunt failure rate of 6% of the children in this series. Two children experienced this complication twice. All collapsed valves were part of a VP shunt system. Because of this experience use of the mini valve was abandoned and an adult Holter valve was implanted in children over the age of one month. Breakdown of this particular valve has not occurred in 102 children and two hundred adults with the adult Holter shunt system.

Occurrence and management of fractured peripheral catheters in CSF shunts.

A series of 716 children underwent 2065 cerebrospinal fluid shunt procedures. Shunt failure due to fracture of the peripheral drain occurred 60 times, 38 times in ventriculo-atrial and 22 times in ventriculo-peritoneal shunts. The break occurred most commonly 2-4 cm above the neck incision in cardiac and just cephalad to the clavicle in abdominal drains. Fifty-nine ruptures occurred in Pudenz catheters (which were used in 82% of the shunts) and 1 occurred in a Holter drain (used in 17%). The fractured atrial catheters remained in situ (5/38) or were dislodged into the right cardiac ventricle (14/38), pulmonary arteries (9/38), right atrium (5/38) or hepatic veins (3/38). Two of the ruptured drains could not be located. Removal by a percutaneous transvascular snare technique was attempted in 27 cases and was successful in 24.

[Brain tumors in children]. / Hjernesvulst hos barn.

Brain tumour was diagnosed by computer tomography or magnetic resonance imaging in 100 children aged 0 to 19 years. They consecutively underwent primary surgical treatment during the years 1984 to 1988. Non-neoplastic lesions and operations for residual tumours are not included. 54 tumours were localized supratentorially. 72% of these were benign or low grade malignancies. 46 tumours had an infratentorial localisation. 59% of these were high grade malignancies. Children tolerate major-neurosurgical procedures better than adults and restitution is usually favourable. 42 children with high grade malignancies underwent postoperative radiotherapy. Per- and postoperative mortality in this series was 1%. 80 children are alive. 62 of these are in excellent condition after a median observation time of 40 months.

Management of pediatric pontine gliomas.

We present 36 consecutive patients with intrinsic glioma of the pons. Tumors with exophytic expansion were excluded. There were 16 females and 20 males, ranging in age from 2 to 13 years, median 6 years. The most common presenting symptoms were cranial nerve dysfunction, unsteadiness of gait, and hemiparesis. Computed tomography (CT) showed a hypodense (17/21) or isodense (4/21) expansion of the pons. Five tumors had areas of contrast enhancement. Following information about prognosis and possible types of management, parents decided for or against radiation therapy: twenty-four children underwent irradiation and 12 did not. Median survival among children receiving a full course of irradiation was 280 days, compared to 140 days in an equivalent group of non-irradiated children. Hemiparesis presenting without cranial nerve symptoms and contrast enhancement on CT scan were poor prognostic factors, whereas sex, age, and duration of symptoms at diagnosis were unrelated to prognosis.