Saffet Mutluer

Intracranial hydatid cysts in children.

Brain involvement in hydatid disease occurs in 1 to 2% of all Echinococcus granulosus infections. Fifty to 75% of intracranial hydatid cysts are seen in children. This study included 19 children who underwent surgery for intracranial hydatid cysts between January 1979 and September 1992. There were 12 boys and 7 girls, ages 3 to 16 years (mean, 8.1 yr). Headache and vomiting were the predominant symptoms. Papilledema was present in 16 patients, and 2 patients had secondary optic atrophy. A round, cystic lesion without perifocal edema and rim enhancement was detected on the computed tomographic scans of 13 patients. The cystic lesions with rim enhancement and perifocal edema were noted on the computed tomographic scans of 3 patients. Of these three patients, two subsequently had a recurrence. Total removal of the cyst without rupture was achieved in 12 patients. Only a 3-year-old boy in whom the cyst ruptured at surgery died. Seven patients in whom either the hydatid cyst ruptured at surgery or there was systemic hydatid disease received mebendazole therapy. Mebendazole seems to be effective in hydatid disease. Cerebral hydatid cysts should be removed in toto without rupture. The preoperative diagnosis is very important in planning surgery. When a cystic lesion is detected on computed tomographic scan, hydatid disease should be taken into consideration in countries where hydatid disease is endemic.

Cerebellar mutism: report of seven cases and review of the literature.

It is well known that degenerative disease, hemorrhage, infection, and neoplastic disease of the cerebellum can lead to speech disorder. Mutism after posterior cranial fossa surgery was first reported by Rekate et al. and Yonemasu in 1985. We review and analyze the cases of cerebellar mutism that are reported in the literature that is available in English. We found 39 reported cases that included details regarding mutism. We review and analyze a total of 46 cases, including those of our seven patients. The ages of the patient ranged from 2 to 61 years (mean, 10.4 yr). Ninety-one percent of the patients were children. The vermis was the site of the mass lesions in > 90% of the cases. The pathological findings of the lesions were as follows: 33 medulloblastomas, 7 astrocytomas, 4 ependymomas, 1 metastatic tumor, and 1 arteriovenous malformation. All mass lesions were considered to be large or very large. The latency for the development of mutism ranged from 0 to 6 days (mean, 1.7 d). The mutism lasted from 4 days to 4 months (mean, 6.8 wk). Dysarthric speech ensued after the mutism was resolved in 35 of 46 patients. Mutism was transient in all of the cases. Cerebellar mutism is a transient complication of posterior fossa surgery for midline mass lesions.

Growing skull fractures (craniocerebral erosion)

Abstract The incidence of growing skull fractures ranges from less than 0.05% to 1.6%. We reviewed 22 growing skull fracture patients retrospectively. There were 15 boys and seven girls ranging in age from newborn to 6 years (mean: 12.4 months) at the time of injury. Falling was the most frequent cause of injury. In total, 17 patients presented with a scalp mass. The scalp was sunken over the bone defect in three patients. Other symptoms and signs were seizure in five patients, hemiparesis in four, recurrent meningitis in one, and pulsatile exophtalmus in one. The most common location was the parietal region. The extent of dural defect was always greater than that of bony defect, except in one case that had been previously shunted for hydrocephalus. In another patient with a growing fracture in the posterior cranial fossa, the dural edges could not be exposed, although a wide craniotomy was performed. Therefore, a cystoperitoneal shunt was inserted. Gliotic tissue was present in all the patients. Cyst or cystic lesions were observed in only nine patients, duraplasty was performed in 21, 16 were neurologically intact, and six had minor deficits. All patients under the age of 3 years with a diastatic skull fracture should be closely followed up. A sustaining diastatic fracture and brain herniation through the skull defect shown on CT or MRI imply a growing skull fracture.

Abdominal cerebrospinal fluid pseudocysts

Abdominal cerebrospinal fluid pseudocyst is an infrequent complication of ventriculoperitoneal (VP) shunts. We reviewed ten patients with abdominal pseudocyst. There were five girls and five boys, aged between 4 months and 14 years. The number of shunt procedures prior to the presentation varied between one and five. Only one patient had had a previous shunt infection. No patients had undergone prior abdominal surgery other than VP shunting. The time from the last shunting procedure to the development of abdominal pseudocyst ranged from 3 weeks to 5 years. Presenting symptoms and signs were mainly related to abdominal complaints in all patients. Three patients also had the signs of shunt malfunction. The diagnosis was made by ultrasound in all patients. Shunt infection was determined in six patients. Repositioning of the peritoneal catheter seemed to have a higher rate of recurrence. The diagnosis of abdominal pseudocyst should be considered in VP-shunted patients presenting with abdominal complaints.

Cerebellar mutism: report of two unusual cases and review of the literature

Mutism is not a common condition following cerebellar damage. Mutism following posterior cranial fossa surgery was first reported by Rekate et al. and Yonemasu in 1985. Since then, many case reports of mutism have appeared in the English literature. Very few cases developed mutism following brain stem surgery. Although mutism has been described in patients with head injury, only one case of mutism caused by a cerebellar injury has been reported, to our knowledge. We report on two patients in which the cerebellar mutism following a radical excision of an exophytic brain stem glioma and cerebellar injury developed. We reviewed the relevant literature and discussed the mechanism of cerebellar mutism.

Pediatric depressed skull fractures : analysis of 530 cases

Depressed skull fractures (DSFs) account for 7–10% of children admitted to hospital with a head injury and 15–25% of children with skull fractures. We reviewed the records of 530 patients operated on for DSF from January 1, 1973, to December 31, 1993. This group was made up of 357 boys (67%) and 173 girls (33%) whose ages ranged from 1 day to 16 years (mean age 6.1 years). Fall was the most common cause of injury. Of the 530 patients with DSF, 66% had compound fractures. the incidence of compound fractures increased with age. Compound fractures caused more brain lacerations (29%) than simple fractures (15.5%) did. We also classified DSFs radiologically as true, flat, or ping-pong ball fractures. Associated intracranial lesions were found to be a bad prognostic factor. There were 13 deaths (2.5%) in this series. Satis-factory results were achieved in over 95% of the patients. Compound fractures are associated with a worse outcome and a higher incidence of intracranial lesions and cortical laceration. Unilateral pupillary dilatation and an admission GCS score of 8 or less are ominous signs in regard to mortality. We also found that the deeper the depressed bone, the higher the risk of both dural tear and cortical laceration and the worse the prognosis. A conservative approach should be followed in cases of simple DSF without associated intracranial hematoma and in cases in which the bone depression is not deeper than 1 cm.

Outcome of patients with meningomyelocele: the Ege University experience.

Abstract The medical records of 190 patients with meningomyelocele operated on between 1979 and 1993 were reviewed. In 65 patients, psychometric tests were performed. The Denver Developmental Screening Test and the Wechsler Intelligence Scale for Children, Revised (WISC-R) were used in children under and over 6 years old, respectively. There were 82 boys (43.2%) and 108 girls (56.8%). The lumbar region was the site of the meningomyelocele in 113 patients (59.5%). Patients with cervical and sacral meningomyelocele had a higher rate of almost normal motor function than those with meningomyelocele at other levels (P=0.000). Only 36 (21.7%) of 166 patients followed up by us did not have hydrocephalus. We also noted that the higher the location of the meningomyelocele, the greater the control of both sphincters (P=0.014). Fifty-four percent of the hydrocephalic patients had a normal development or IQ. Psychometric tests were normal in 76% of those without hydrocephalus. Twenty-four patients were lost to follow-up. The follow-up of the remaining 166 patients ranged from 1 month to 180 months (mean 60.2 months). Fifty-three patients (32%) died, central nervous system infection being the most common cause of death (44%). The management of children with meningomyelocele needs a team approach.

Brain abscess in infants and children

Forty-four consecutive patients with brain abscesses, aged between 1 month and 16 years, were reviewed. The cause of abscess was menigitis in 36% of the cases, otitis in 27%, heart disease in 9%, other in 5%, and undetected in 5%. Thirty patients had a single abscess and 12 had multiple abscesses. Multiloculated abscess was present in 2. Total excision was accomplished in 22 patients. Three patients underwent needle aspiration. Drainage of the abscess was performed in 13. Secondary excision was needed in 5 patients. One patient was treated nonsurgically. Streptococci, staphylococci and Proteus mirabilis were the microorganisms recovered in cultures. Overall mortality was 20% (9 patients). Mortality was significantly higher in patients under 2 years of age than in those older. Of 15 patients who were comatose at the time of admission, 6 died. Etiology, diagnostic method, and treatment modalities were not found to be significant factors in terms of predicting mortality.

Split Cord Malformations: Report of Three Unusual Cases

The unified theory, proposed by Pang et al., explains the embryogenetic mechanisms of all variants of split cord malformations (SCMs). All SCMs originate from one basic error occurring around the time when the primitive neurenteric canal closes. The basic error is the formation of an accessory neurenteric canal between the yolk sac and amnion which is subsequently invested with mesenchyme to form an endomesenchymal tract that splits the notochord and neural plate. Three cases of SCMs which support this unified theory are presented. A 3-month-old girl had a combination of both types of SCMs at the level of T11. The 2nd case, a 2-week-old girl, had type-II SCM associated with a thickened filum terminale, lipomyelomeningocele and ectopic renal tissue within lipoma. A lipomatous tract extending from a subcutaneous lipoma to the intradural fibrous septum contained lymphoid tissues and tubular epithelia in a 3-month-old boy with a type-II SCM. These 3 cases support the unified theory.

Intracranial meningeal tumours in childhood: a clinicopathologic study including MIB-1 immunohistochemistry.

Primary tumours of the meninges with a relatively high tendency for malignant behaviour are uncommon in childhood. This study concerns 18 cases of meningeal tumours in children under the age of 16, of which 13 were meningiomas and five were other tumours arising in the meninges. Meningiomas showed a preponderance in females as in adult series, and the majority were supratentorial in localisation. The percentage of meningeal tumours and meningiomas among all brain tumours in our centre were 3.72% and 2.69%, respectively. Four out of 13 meningiomas were fibroblastic, four were transitional, one was meningothelial, two were psammomatous and two were papillary meningiomas. Seven (38.8%) out of 18 tumours showed anaplastic features, including two papillary meningiomas, two hemangiopericytomas, one mesenchymal chondrosarcoma, one pleomorphic sarcoma and one anaplastic meningeal tumour. Papillary meningiomas with hemangiopericytoma-like solid areas were seen frequently in our cases (15.3%). Meningoangiomatosis was associated with two meningeal tumours. MIB1 (Ki-67) labelling indices (LIs) ranged between 0% and 13.6% (mean 1.83%) in benign, and between 1% and 20% (mean 7.2%) in malignant tumour, including papillary meningiomas. Mean MIB-1 LIs were 5.61% and 1.14% in non-recurrent and recurrent cases, respectively. MIB-1 LIs showed significant differences between benign and malignant meningeal tumours but no significant correlation either with prognosis or recurrence. Despite the fact that brain tumours are among the most common neoplasms of childhood, meningeal tumours are rare lesions, accounting for less than 2% of published series of intracranial neoplasms in childhood [5, 8, 18, 24, 30, 32]. It has been suggested that the clinical and pathological characteristics of meningiomas in this age group differ from those of adults [14, 18, 24, 45]. Besides meningiomas, there are a few reports of other meningeal tumours in childhood and difficulties in differential diagnosis may arise within this group, especially in anaplastic tumours [11, 13, 32, 44, 46]. One of the major problems in meningiomas and some tumours arising in the meninges is the discordance that arises between the histologic appearance of the tumour and behaviour [4]. Several studies have attempted to determine the proliferation potential of meningiomas, including immunohistochemical labelling with monoclonal antibodies to Ki-67, proliferating cell nuclear antigen (PCNA), and bromodeoxyuridine (BUdR); flow cytometric DNA analysis; or argyrophilic nucleolar organizer regions (AgNORs) counting [9, 10, 15, 19, 22, 26, 31, 35, 53]. The studies concerning proliferation markers have contradictory results [9, 10, 15, 26, 31, 42, 53]. MIB-1 detects the same or a similar epitope as the original antibody Ki-67 and reacts with a proliferation associated antigen expressed in all active parts of the cell cycle, G1, S, G2 and M (mitosis), but not in the G0 or quiescent phases [7]. In this study we examined the clinicopathological characteristics and MIB1 values of 18 meningeal tumours in children under the age of 16 years within the last 25 years (from 1970 to 1995).