Ashutosh Singhal

Cerebrospinal fluid (CSF) leak and pseudomeningocele formation after posterior fossa tumor resection in children: a retrospective analysis

ObjectiveThe purpose of this study was to determine the incidence of pseudomeningocele and cerebrospinal fluid (CSF) leak after posterior fossa tumor surgery and to analyze factors that may be associated with these conditions. In particular, we wished to determine if there was evidence to support the hypothesis that the use of tissue glue, dural grafts, or external ventricular drainage (EVD) prevented CSF from leaking outside the closed dura.Materials and methodsA retrospective chart review was carried out of posterior fossa tumor resections at British Columbia’s Children’s Hospital. Information was collected regarding tumor location, surgical approach, CSF diversion, dural grafting, and use of tissue glue. Multiple univariate analyses and step-wise logistic regression were performed to identify factors associated with pseudomeningocele formation or CSF leak. A pseudomeningocele was said to be present if it was noted in the clinical records or if a fluid collection was present superficial to the craniotomy flap on a postoperative CT or MR scan.ResultsOut of 174 posterior fossa operations, 53 pseudomeningoceles with or without CSF leak were identified along with five CSF leaks in the absence of pseudomeningocele (33%). None of the factors examined reached statistical significance, although there was a trend towards higher rates in patients with external CSF drainage (P=0.06631), dural graft usage (p=0.06492), and patients in whom tissue glue was used (p=0.06181). On logistic regression, only tissue glue use and external CSF drainage were associated with increased incidence of pseudomeningocele and/or CSF leak.ConclusionIn this retrospective study, the use of tissue glue, dural grafts, and external ventricular drainage was not associated with a reduced rate of clinically or radiologically diagnosed pseudomeningocele formation or postoperative CSF leak. The results of this study provide a basis for planning a randomized controlled trial to determine the effectiveness of tissue glue and/or dural grafting in preventing these complications.

EARLY HYPODENSITY ON COMPUTED TOMOGRAPHIC SCAN OF THE BRAIN IN AN ACCIDENTAL PEDIATRIC HEAD INJURY

OBJECTIVEHypodensities on computed tomographic (CT) brain scans are thought to take at least 6 hours to become apparent after blunt head trauma. This finding, in conjunction with the later evolution of the hypodensities, is used in timing the injury in children with suspected non-accidental brain injury, in whom the history may be inaccurate. The purpose of this study is to report the occurrence of diffuse cerebral parenchymal hypodensities on CT scans performed within 5 hours of a well-defined accidental head injury. METHODSA retrospective review was performed of five patients admitted to British Columbia Childrens Hospital who had accidental head injury and who were identified as having diffuse cerebral hemispheric hypodensities on early CT scans. RESULTSWe present five patients (age range, 4 mo–14 yr) with well-documented accidental head injuries who demonstrated obvious and extensive CT brain scan cerebral hemispheric hypodensity from 60 minutes to 4.5 hours after trauma. All five patients presented with severe head injuries and immediate, unremitting coma, and all five progressed rapidly to brain death within 48 hours. CONCLUSIONIt is unusual, but possible, to develop CT hypodensities as early as 1 hour after accidental head injury. In our small series of cerebral hemispheric hypodensity occurring less than 5 hours after trauma, all five patients had a uniformly fatal outcome. These observations may be important medicolegally in the assessment of the timing of head injury when the history of the trauma is not clear, as in children with suspected non-accidentally inflicted injury. It is inappropriate to generalize these findings to patients who are not unconscious immediately after a head injury, who regain consciousness after an injury before deteriorating, or who do not progress rapidly to brain death.

Operative management of growing skull fractures: a technical note

ObjectsGrowing skull fractures can be a challenging surgical problem facing the pediatric neurosurgeon. The goal of this manuscript is to clarify effective surgical methods and to provide the rationale for these techniques.MethodsWe describe the surgical techniques for treatment of growing skull fractures. We clarify the underlying concepts, with respect to dural closure and repair of bony defects, that have led to these techniques.ConclusionsWith effective surgical technique, the pediatric neurosurgeon can effectively treat growing skull fractures, with excellent outcomes in terms of bony coverage and cosmesis.

Endoscopic fenestration of cavum velum interpositum cysts: a case study of two symptomatic patients

IntroductionCavum velum interpositum (CVI) is commonly an incidental asymptomatic finding on imaging studies. Encystment can occur and, in most situations, is also asymptomatic. Clinical symptoms occurring in patients with CVI cysts have been reported infrequently with the result that the relationship of these symptoms and the cyst are usually unclear. This report contributes to the knowledge base of symptoms that can occur in patients with CVI and the response of symptoms to effective treatment.Patients and methodsWe report the clinical outcomes of a 3-year-old male patient and a 13-year-old female patient with symptoms and CVI cysts on imaging who were treated successfully with endoscopic fenestration.ResultsThe developmental delay and occasional headache present in the 3-year-old male patient resolved after endoscopic fenestration; however, the 13-year-old patient who had neuropsychiatric symptoms did not improve.ConclusionsOur cases add to the literature describing the response to cyst treatment in symptomatic patients harboring CVI cysts. Symptoms due to CSF pathway obstruction may respond to cyst fenestration, while the response of symptoms in patents who do not have clear CSF circulation disorders is less predictable.

Gyriform Differentiation in Medulloblastoma – A Radiological Predictor of Histology

Medulloblastoma with extensive nodularity (MBEN) is a variant with an apparently favorable outcome. The authors describe a 2-month-old child with MBEN who had a characteristic gyriform morphology on MR imaging preoperatively and was found to have local metastasis into the adjoining cerebellum on histopathological examination. This case illustrates that histological subtyping may be possible based on the imaging morphology in selected tumors, which may have a bearing on the management of these tumors.

The assessment of management morbidity in children with myelomeningocoele

Address: 1Division of Paediatric Neurosurgery, British Columbias Childrens Hospital, 4480 Oak St, #K3-159, Vancouver, BC, Canada, 2Myelomeningocoele Program, Department of Paediatric Neurosciences, British Columbias Childrens Hospital, 4480 Oak St, #K3-159, Vancouver, BC, Canada and 3Department of Paediatric Neurosciences, British Columbias Childrens Hospital, 4480 Oak St, #K3-159, Vancouver, BC, Canada

Impact of Early Follow-Up Intervention on Parent-Reported Postconcussion Pediatric Symptoms: A Feasibility Study.

Objectives:To investigate the effectiveness and feasibility of early intervention telephone counseling with parents in limiting postconcussion symptoms and impacts on children and youth. Setting:Recruitment occurred postdischarge from one pediatric emergency department. Participants:Sixty-six parents of children aged 5 to 16 years with a diagnosis of a concussion injury. Design:A pilot, randomized controlled study compared the efficacy of telephone counseling (reviewing symptom management and return to activity with parents at 1 week and 1 month postinjury) with usual care (no formalized follow-up). Main Measures:The Post-Concussion Symptom Inventory and the Family Burden of Injury Interview administered with parents by a blinded therapist at 3 months postinjury. Results:No significant difference between the groups at 3 months postinjury in postconcussion symptoms (P = .67) and family stress (P = .647). Conclusion:The findings suggest that the early counseling intervention strategy trialed herein may not be effective for children and youth who experience significant postconcussion symptoms. Further research is needed to determine whether more intensive and integrated care would better serve children.

Bilateral lambdoid and posterior sagittal craniosynostosis--management, evolution, and outcome.

Bilateral lambdoid and posterior sagittal synostosis (BLSS) is a rare disorder characterized by invagination of the occipital squame resulting in a step-like deformity of the occiput, and a typical head shape described as anterior turricephaly with mild brachycephaly. Neuhauser et al. were the first to report about this rare multisutural synostosis which they termed “craniofacial dyssynostosis” and proposed an autosomal recessive mode of inheritance to explain their findings [8]. Four of the seven patients they described were of Spanish/Mexican/Puerto Rican ancestry and had several features in common including an abnormal head shape, variable developmental delay, and short stature. Following this initial report, a few other authors have also reported their experience [1, 5, 7]. Moore et al. coined the term “Mercedes Benz pattern” in a report of three children who had presented with sagittal and bilateral lambdoid synostosis [6]. Associated anomalies include the Chiari I malformation (CM), hydrocephalus, and skull venous anomalies. The occipital contour and mild or moderate ventricular enlargement respond to synostectomy and foramen magnum decompression (FMD). The literature on how the CM, hydrocephalus, and the shape of the head evolve with time is limited. Similarly, the problem of the timing of the various surgeries to address these issues has not been resolved. The management of our most recent patient with this disorder focused our attention on several of these unresolved issues and hence, we decided to review our own experience with BLSS. The specific questions that we reviewed were: (1) Do the venous anomalies have a significant impact on surgery? (2) How does the CM evolve following early FMD? (3) How often does a syrinx develop in this condition? (4) Does the hydrocephalus require further management? (5) Does the anterior turricephaly resolve with posterior decompression?