Use of Vacuum-suction in Depressed Skull Fractures ­ Case Report and Technical Nuances of Nonoperative Treatment

Up to 20% of victims from skull fractures are represented by the pediatric population, and 50% of these lesions are depressed skull fractures. The treatment is multimodal in nature, ranging from conservative treatment to open surgical repair. The last one is associated, although in a small proportion, to complications, such as infections, hematomas and even death, besides the risks of the anesthetic procedure itself. The authors of the present article present a case report of the successful treatment of a depressed skull fracture in a newborn patient, using the vacuum-suction technique. The use of vacuum-suction may be beneficial for the pediatric patients, as it is a quick, non-invasive procedure, without the need for general anesthesia.

Tratamiento endoscópico de lesiones quísticas supratentoriales en pediatría / Endoscopic treatment of supratentorial cystic lesions in pediatrics

Introducción: La endoscopía neuroquirúrgica es una técnica mínimamente invasiva, utilizada desde principios del siglo XX para dar solución a las patologías localizadas en el sistema ventricular. En la actualidad las indicaciones de esta técnica se han ampliado notablemente. El objetivo de este trabajo consiste en presentar el tratamiento endoscópico de quistes cerebrales supratentoriales de diferentes etiologías en pediatría. Materiales y métodos: Se realizó un estudio transversal retrospectivo, desde enero de 2016 hasta diciembre de 2019, de pacientes pediátricos con lesiones quísticas supratentoriales tratados endoscópicamente en el Hospital de Niños de La Plata. Para definir el éxito se utilizó la clasificación en 5 grados de Ross et al. Resultados: Se practicaron 14 procedimientos en 12 pacientes, con edades comprendidas entre los 2 meses y los 9 años. Del total, 6 fueron quistes intraventriculares, 3 quistes de línea media, 5 quistes paraventriculares. Todos presentaban algún signo o síntoma al momento de la consulta, predominando entre ellos la alteración del estado neurológico y los vómitos. Luego de practicarse la fenestración endoscópica, presentaron una evolución clínica favorable en 12 de los 14 procedimientos y una mejoría en al menos un criterio imagenológico en 10 del total de los procedimientos.Basados en la categorización de Ross et al. se obtuvo un grado I en el 57% de los casos, lo que implica una mejoría completa permanente. La tasa de complicación global fue del 7%, presentando en solo un caso infección post endoscopia. Conclusión: La neuroendoscopía debería ser considerada como una opción de primera línea para el tratamiento en las lesiones quísticas supratentoriales. Demostró ser un método poco invasivo, con el cual se obtuvieron buenos resultados y una baja tasa de complicaciones.

Introduction: Neurosurgical endoscopy is a minimally invasive technique, used since the beginning of the 20th century to solve pathologies localized in the ventricular system. Currently the indications for this technique have been greatly expanded. The objective of this work is to present the endoscopic treatment of supratentorial brain cysts of different etiologies in pediatrics. Material and methods: We carried out a retrospective cross-sectional study, from January 2016 to December 2019, of pediatric patients with supratentorial cystic lesions treated endoscopically at the Hospital de Niños of La Plata City. To define success, we used the 5-degree classification of Ross et al. Results: 14 procedures were performed in 12 patients, aged between 2 months and 9 years. Of the total, 6 were intraventricular cysts, 3 midline cysts, 5 paraventricular cysts. All presented any signs or symptoms at the time of the consultation, prevailing among them the alteration of the neurological state and vomiting. After endoscopic fenestration was performed, they presented a favorable clinical evolution in 12 of the 14 procedures and an improvement in at least one imaging criterion in 10 of all procedures. Based on the categorization of Ross et al. we obtained a grade I in 57% of the cases, which implies a permanent complete improvement. The overall complication rate was 7%, presenting post-endoscopy infection in only one case. Conclusion: Neuroendoscopy should be considered as a first-line option for the treatment of supratentorial cystic lesions. It proved to be a non-invasive method, with which we obtained good results and a low complication rate

Neuroendoscopic surgery in children: an analysis of 200 consecutive procedures / Neuroendoscopia em crianças: uma análise de 200 procedimentos consecutivos

Neuroendoscopic surgery in children has particular features and is associated with different success rates (SR). The aim of this study was to identify putative factors that could influence the outcome in pediatric patients.

Clinical data of 177 patients under 18 years of age submitted to 200 consecutive neuroendoscopic procedures from January 2000 to January 2010 were reviewed. The overall success rate was 77%. Out of the patients with successful outcomes, 46% were under six months, 68% were between six months and one year of age, and 85% older than one year. Neuroendoscopic techniques provide very good results for a wide number of indications in children. Tumor-related cerebrospinal fluid (CSF) circulation problems and aqueductal stenosis seem to be particularly well suited to neuroendoscopic treatment regardless of the patient's age. Patients' age and etiology of hydrocephalus were associated with a different outcome. In all cases, surgical experience is extremely important to reduce complications. .

A cirurgia neuroendoscópica em crianças apresenta particularidades e está associada a diferentes taxas de sucesso (TS). O objetivo deste estudo consistiu em identificar fatores que pudessem influir no resultado do tratamento em pacientes pediátricos. Dados clínicos de 177 pacientes com idade inferior a 18 anos submetidos a 200 procedimentos neuroendoscópicos consecutivos entre janeiro de 2000 e janeiro de 2010 foram revisados. A taxa de sucesso global foi de 77%. Os pacientes com idade inferior a seis meses apresentaram taxa de sucesso de 46%; pacientes entre seis meses e um ano de vida obtiveram êxito em 68% dos casos; dentre os maiores de um ano, 85% dos procedimentos foram bem-sucedidos. Técnicas neuroendoscópicas proporcionam muito bons resultados para uma grande variedade de indicações em crianças. Independentemente da faixa etária, o tratamento endoscópico apresenta-se particularmente adequado para problemas da circulação liquórica relacionados a tumores e à estenose aquedutal. A faixa etária dos pacientes e a etiologia da hidrocefalia estão associadas a diferentes resultados. Em todos os casos, experiência neurocirúrgica é extremamente importante para a redução das complicações. .

Surgical management of pediatric Cushing's disease: an analysis of 15 consecutive cases at a specialized neurosurgical center / Estratégia cirúrgica na doença de Cushing em pacientes pediátricos: análise de 15 casos consecutivos operados em centro neurocirúrgico especializado

OBJECTIVE: The aim of this study was to review the results of surgery for pediatric patients with Cushing's disease who were less than 18 years old and underwent transsphenoidal surgery in a specialized center during a 25-year period. SUBJECTS AND METHODS: Retrospective study, in which the medical records, histology and pituitary imaging of 15 consecutive pediatric patients with Cushing's disease (mean age: 13 years) were evaluated by the same team of endocrinologists and a neurosurgeon from 1982 to 2006. Patients were considered cured when there was clinical adrenal insufficiency and serum cortisol levels were below 1. 8 µg/dL or 50 nmol/L after one, two, three, or seven days following surgery; they therefore required cortisone replacement therapy. Follow-up was for a median time of 11.5 years (range: 2 to 25 years). RESULTS: Clinical and biochemical cure was achieved in 9/15 patients (60 percent) exclusively after transsphenoidal surgery. Hypopituitarism was observed in four patients; growth hormone deficiency, in two; permanent diabetes insipidus, in one case. CONCLUSIONS: Cushing's disease is rare in children and adolescents. Transsphenoidal surgery is an effective and safe treatment in most of these patients. Plasma cortisol level < 1. 8 µg/dL following surgery is the treatment goal and is a good predictive factor for long-term cure of Cushing's disease.

OBJETIVO: O objetivo deste estudo foi avaliar os resultados cirúrgicos em pacientes pediátricos com doença de Cushing com idade inferior a 18 anos, submetidos à cirurgia transfenoidal num centro especializado, durante um período de acompanhamento de 25 anos. SUJEITOS E MÉTODOS: Estudo retrospectivo dos prontuários médicos de 15 pacientes pediátricos com doença de Cushing (idade média de 13 anos), sendo avaliados aspectos clínicos, laboratoriais, histológicos e radiológicos. Todos os pacientes foram avaliados pela mesma equipe de endocrinologistas e operados por um mesmo neurocirurgião, entre 1982 e 2006. O tempo médio de seguimento foi 11,5 anos (2 a 25 anos). Os pacientes foram considerados curados quando houve insuficiência adrenal e níveis de cortisol plasmático inferiores a 1,8 µg/dL ou 50 nmol/L no pós-operatório um, dois, três ou sete dias após a cirurgia; estes pacientes necessitaram de reposição de corticosteroide. RESULTADOS: Cura clínica e bioquímica foi alcançada em 9/15 pacientes (60 por cento) após a cirurgia transfenoidal. Hipopituitarismo foi observado em quatro pacientes; déficit de hormônio de crescimento, em dois; diabetes insípido permanente, em um. CONCLUSÕES: A doença de Cushing é rara na infância e na adolescência. A cirurgia transfenoidal é um tratamento efetivo e seguro para a maioria dos pacientes. Uma concentração de cortisol plasmático < 1,8 µg/dL nos primeiros dias pós-cirurgia transfenoidal é o objetivo do tratamento e um fator preditivo tardio para a cura da doença de Cushing.

Intramedullary Entire Spinal Cord Abscess Secondary to a Congenital Dermal Sinus: A Case Report

Intramedullary spinal abscesses are rare and potentially devastating lesions. The first case of spinal abscess was described in 1830 and fewer than 100 cases have been reported subsequently. Only sixteen previous reports have described an intramedullary abscess of the central nervous system secondary to a dermal sinus. Involvement of the entire cord is thus exceedingly rare. We present a case of a 7-month-old girl who had rapidly progressing quadriplegia with urinary and bowel retention and was found to have an intramedullary abscess as a result of a dermal sinus. Spine MRI shows thick irregular ring enhancement appeared within the broadest area of the spinal cord on the thoracic and lumbar area on mid thoracic level to L3 and high cervical area which extended to medulla. Immediate decompressive surgery and antibiotic treatment were performed. Excellent clinical outcome was obtained with a combination of medical and surgical management. Complete neurological assessment and diagnostic study of all patients with a congenital dermal sinus are very important. Prophylatic surgery is indicated in many cases to prevent dangerous and recurrent infections of the central nervous system.

Spontaneous acute subdural hematoma contralateral to an arachnoid cyst

Arachnoid cysts (AC) are extra-cerebral cerebrospinal fluid collections of unknown origin. They correspond to 1 percent of all intracranial nontraumatic space-occupying lesions and appear more frequently in the middle fossa (50 percent). More than 25 percent of these cysts are incidental findings and the majority of patients are asymptomatic. Seizures, intracranial hypertension signs, neurological deficits, macrocrania, developmental delay and bulging of the skull are the main signs and symptoms of the lesion. AC rupture and bleeding are rare, usually occurring in young adults and associated with trauma. The risk of hemorrhage does not exceed 0.04 percent / year. We describe the case of a ten-year-old boy who presented with acute signs of intracranial hypertension secondary to a spontaneous acute subdural hematoma, contralateral to an AC of the middle fossa. Three factors were significant in this case: signs and symptoms occurred spontaneously; the presence of an acute subdural hematoma exclusively contralateral to the AC; successful outcome of the conservative treatment.

Os cistos aracnóideos (CA) são coleções liquóricas extra-cerebrais e intra-aracnóideas de origem desconhecida. Correspondem a 1 por cento de todas as lesões expansivas intracranianas não traumáticas e têm nítido predomínio na fossa média (50 por cento). Até 25 por cento destes cistos são achados incidentais sendo que a maioria dos pacientes é assintomática. Crises epilépticas, sinais de hipertensão intracraniana, déficits neurológicos focais, macrocrania, atraso no desenvolvimento e abaulamento da calota craniana são os principais sinais e sintomas da lesão. A ruptura dos CA, assim como seu sangramento, são situações raras, geralmente associadas a traumas e acometem adultos jovens. O risco de hemorragia em pacientes com CA não excede 0,04 por cento ao ano. É descrito caso de paciente de dez anos de idade que subitamente apresentou sinais de hipertensão intracraniana secundários a hematoma subdural agudo espontâneo, contralateral a volumoso CA de fossa média. Três fatores foram de relevância neste paciente: a ocorrência de sinais e sintomas espontaneamente, especialmente em um menino; presença de hematoma subdural agudo exclusivamente contralateral ao CA; e a boa evolução com o tratamento conservador.

Meningeoma de terceiro ventrículo em criança / Third ventricle meningioma in a child

Meningeomas localizados nos ventrículos são bastante raros, ocorrendo em torno de 1,5% a 2% dos casos, e no terceiro ventrículo localizam-se apenas 15% desses. O processo torna-se mais raro quanto menor a idade. Apresentamos um caso de meningeoma de terceiro ventrículo, com expansão para os ventrículos laterais, principalmente o direito, em uma criança de 11 anos. Segundo a família, aos 9 anos apresentou cefaléia e, na época, atendida por neurologista, foi medicada com fenitoína, tendodesaparecido o quadro. Três meses antes de procurar o nosso Serviço, começou novamente a ter cefaléia di fusa, de caráter progressivo. Foi submet ida a exames que most raram processo expansivo no terceiro ventrículo, com expansão para ventrículos laterais, bastante vascularizado, bem delimitado e originando-se ao nível do plexo coróide. Foi submetida à cirurgia e o diagnóstico histopatológico foi de meningeoma psamomatoso.

Meningiomas located in the cerebral ventricles are quite rare, being reported in 1.5% to 2% of all cases, and only 15% of these are located in the third ventricle. The process becomes rarer as the age decreases.We present a case of meningioma of the third ventricle, with expansion into the lateral ventricles, mainly to the right, in a 11 year-old girl. According to her family, two years before admission in our Service she presented headache; phenytoin prescribed elsewhere had alleviated the complaint.Three months before she started again to have diffuse and progressive headaches. She was submitted to CT and MRI that showed a well delimited tumor in the third ventricle with expansion into the lateral ventricles.She was submitted to surgery and the histopathology confirmed the diagnosis of psamomatosus meningioma.