Pediatric suprasellar lesions.

Pediatric brain tumors have always been challenging as well as intriguing in their anatomical, surgical, and postsurgical management-related issues. They are a heterogeneous set of pathologies involving different age groups in childhood and also differ widely from their adult counterparts as far as adjuvant therapies are concerned. Though neurosurgeons across the world are radical in surgery for most of the pediatric tumors, it can often be at the cost of future quality of life in suprasellar tumors. As the time has gone by, the pendulum has swung toward rather conservative and maximal safe surgical resections with adjuvant therapies coming to the forefront. Hence, the aim is to achieve a good quality of life for these children along with a control of tumor growth (rather than cure) and to again tackle the tumors, if required, once these children reach adolescence or adulthood. We have reviewed the literature for different pediatric suprasellar tumors and discussed their current management giving our perspective with illustrative cases.

Utility of ventricular access in an acute deterioration after endoscopic third ventriculostomy.

Endoscopic third ventriculostomy (ETV) has now been accepted widely as a safe procedure for treatment of non-communicating hydrocephalus. Despite its learning curve, most of the neurosurgeons have understood its technical details, benefits, and risks and have started to practice it to perfection. The benefit of shunt independence with minimal risks offers a remarkable advantage which has made this procedure widely popular. However, late closure of stoma leading to morbidity and even death has been reported off late. We report a case of a 7-year-old girl with hydrocephalus due to tectal glioma who deteriorated after 7 months following a successful procedure. She developed a cardio-respiratory arrest and was resuscitated with aspiration of cerebrospinal fluid from the ommaya reservoir kept during the primary surgery. Keeping all the patients under strict surveillance for stoma patency is mandatory and in addition, ommaya reservoir in certain high-risk patients may be a useful option for achieving quick ventricular access by medical and nonmedical personnel in case of deterioration. This case is the first reported case of acute deterioration after ETV from India. Previously, 14 such cases have been reported worldwide and only 2 of them have survived.

Postoperative brain stem tension pneumocephalus causing transient locked-in syndrome.

The incidence of pneumocephalus after supratentorial craniotomy has been reported to be as high as 100%. However, transformation of postoperative pneumocephalus into tension pneumocephalus (symptomatic intracranial air) is a rather rare phenomenon. Tension pneumocephalus after posterior fossa surgery is reported mainly when the surgery is performed in a sitting position. We hereby report on a patient who developed brain-stem tension pneumocephalus in the early postoperative period after posterior fossa craniotomy for an exophytic brainstem astrocytoma, operated in the prone position. A complete locked-in syndrome resolved following surgical relief of the trapped air.

Prophylactic antibiotics in pediatric shunt surgery.

INTRODUCTION: The optimal antibiotic prophylaxis for pediatric shunt-related procedures is not clear. There is much inconsistency among different medical centers. This paper summarizes and analyzes the various prophylactic antibiotic regiments used for shunt-related surgeries at different pediatric neurosurgery centers in the world. MATERIALS AND METHODS: A survey questionnaire was distributed through the Pediatric Neurosurgery list-server (an e-mail-based special interest group in pediatric neurosurgery). Forty-five completed questionnaires were received, one per medical center, primarily from pediatric neurosurgeons with the following geographic breakdown: 25 from North America, 13 from Europe, and 7 from Asia and other countries. All centers routinely administered prophylactic antibiotics for shunt-related procedures. The drugs of choice were first-generation cephalosporins (23), second-generation cephalosporins (10), naficillin/oxacillin (4), vancomycin (3), clindamycin (1), amoxicillin (1), and mixed protocols in three centers. The initial drug administration ("first dose") was: in the department before transfer to operating room (5), upon arrival to operating room (11), at induction of anesthesia (13), and at initial skin incision (16). The duration of antibiotic dosage also varied: single dose (13), 24-h administration (26), 48-h administration (2), and longer than 48 h in four centers. RESULTS AND DISCUSSION: Two general tendencies were noted, common to the majority of participating centers. There was a general trend to modify antibiotic treatment protocol in "high-risk" populations. The second common theme noted in more than half of responding centers was the use of long-term antibiotic treatment for externalized devices (such as externalized shunts, external ventricular drains or lumbar drains), usually till the device was in place.