Pediatric intracranial tuberculoma: illustrative case.

BACKGROUND: Tuberculosis is an airborne disease caused by Mycobacterium tuberculosis. Intracranial tuberculoma is a rare complication of extrapulmonary tuberculosis due to hematogenous spread to subpial and subependymal regions. Intracranial tuberculoma can occur with or without meningitis. OBSERVATIONS: A 3-year-old male who had recently emigrated from Sudan presented to the emergency department with right-sided seizures lasting 30 minutes, which were aborted with levetiracetam and midazolam. Head computed tomography revealed a multilobulated left supratentorial mass with solid and cystic components and measuring 8.0 × 4.8 × 6.5 cm. The patient had successful resection of the mass, which was positive for M. tuberculosis. He was started on rifampin, isoniazid, pyrazinamide, ethambutol, and fluoroquinolone and was discharged home in stable condition. LESSONS: A literature review on pediatric intracranial tuberculoma was performed, which included 48 studies (n = 49). The mean age was 8.8 ± 5.4 years with a slight female predilection (59%). Predominant solitary tuberculomas (63%) were preferentially managed with both resection and antituberculosis therapy (ATT), whereas multifocal tuberculomas were preferentially managed with ATT. Intracranial tuberculoma is a rare but treatable cause of space-occupying lesions in children. Clinicians should maintain a high level of suspicion in patients from endemic regions and involve the infectious disease service early.

Use of Antibacterial Envelopes for Prevention of Infection in Neuromodulation Implantable Pulse Generators.

BACKGROUND: Neuromodulation unit placement carries a historic infection rate as high as 12%. Treatment of such requires surgical removal and a long course of systemic antibiotics. Antibiotic-impregnated envelopes have been effective in preventing infection in implantable cardiac devices. At our center, 1 surgeon uses these envelopes with all implanted neuromodulation units. OBJECTIVE: To assess the efficacy of antibacterial envelopes in prevention of infection in neuromodulation device placement. METHODS: We conducted a retrospective cohort study of consecutive implantable pulse generator (IPG) unit implantation with an antibacterial envelope at a single center between October 2014 and December 2019. We collected demographic data, including postoperative infections, reoperations, and complications, associated with the IPGs. This cohort was then compared with a historical cohort of consecutive patients undergoing surgery before envelope usage (October 2007-April 2014). RESULTS: In the pre-envelope cohort of 151 IPGs placed in 116 patients, there were 18 culture-confirmed infections (11.9%). In the antibacterial envelope cohort of 233 IPGs placed in 185 patients, there were 5 culture-confirmed infections (2.1%). The absolute risk reduction of the antibacterial envelope was 9.85% (95% CI 4.3%-15.4%, P < .01). The number needed to treat was 10.1 (95% CI 6.5-23.1, P < .01) envelopes to prevent 1 IPG infection. CONCLUSION: We saw a reduced rate of infections in the antibacterial envelope cohort. Although this is likely multifactorial, our results suggest a benefit of antibacterial envelopes on infection after neuromodulation surgery.

Migration of a swallowed needle into the cervical spine: case report.

Foreign body migration into the cervical spine is rare. Only 3 prior reports of needle migration into the cervical spine exist in the literature. Here, the authors report one such case, where the migrated needle narrowly avoided the thecal sac and vertebral artery. To the authors' knowledge, this is the first report of a migrated swallowed foreign body in the cervical spine.

Cerebellar mutism after posterior fossa tumor resection in children: a multicenter international retrospective study to determine possible modifiable factors.

PURPOSE: A preliminary survey of pediatric neurosurgeons working at different centers around the world suggested differences in clinical practice resulting in variation in the risk of pediatric cerebellar mutism (CM) and cerebellar mutism syndrome (CMS) after posterior fossa (PF) tumor resection. The purposes of this study were (1) to determine the incidence and severity of CM and CMS after midline PF tumor resection in children treated at these centers and (2) to identify potentially modifiable factors related to surgical management (rather than tumor biology) that correlate with the incidence of CM/CMS. METHODS: Attending pediatric neurosurgeons at British Columbia's Children's Hospital (BCCH) and neurosurgeons who completed a pediatric neurosurgery fellowship at BCCH were invited to provide data from the center where they currently practiced. Children aged from birth to less than 18 years who underwent initial midline PF tumor resection within a contemporary, center-selected 2-year period were included. Data was obtained by retrospective chart and imaging review. Modifiable surgical factors that were assessed included pre-resection surgical hydrocephalus treatment, surgical positioning, ultrasonic aspirator use, intraoperative external ventricular drain (EVD) use, surgical access route to the tumor, and extent of resection. CM was defined as decreased or absent speech output postoperatively and CMS as CM plus new or worsened irritability. RESULTS: There were 263 patients from 11 centers in 6 countries (Canada, Germany, the Netherlands, India, Indonesia, and the USA). Median age at surgery was 6 years (range < 1 to 17 years). The overall incidence of postoperative CM was 23.5% (range 14.7-47.6% for centers with data on ≥ 20 patients). The overall incidence of CMS was 6.5% (range 0-10.3% for centers contributing data on ≥ 20 patients). A multivariate logistic regression on the full data set showed no significant association between pre-resection surgical hydrocephalus treatment, prone position, ultrasonic aspirator use, EVD use, telovelar approach, complete or near total resection, or treating center and either postoperative CM or CMS. CONCLUSIONS: While there was variation in surgical management of midline PF tumors among centers participating in this study, the factors in management that were examined did not predict postoperative CM or CMS.

Forced normalization after turning off vagus nerve stimulation in Lennox-Gastaut syndrome.

Forced normalization is the development of psychiatric symptoms in a patient experiencing remission of seizures. We present a case of Lennox Gastaut syndrome in which forced normalization developed after vagus nerve stimulation was stopped. The patient had drug resistant epilepsy and failed anti-seizure drugs, vagus nerve stimulation, and a partial callosotomy. The patient had multiple types of seizures including drop attacks, absences, and tonic-clonic seizures. He tried vagus nerve stimulation for two years without success. Forced normalization developed after the vagus nerve stimulator was turned off. This is the first case to our knowledge to describe forced normalization after turning off the vagus nerve stimulator.

Efficacy of Vagal Nerve Stimulation for Drug-Resistant Epilepsy: Is it the Stimulation or Medication?

BACKGROUND: Vagus nerve stimulation (VNS) therapy has been widely recognized as an alternative for the treatment of drug-resistant epilepsy, although modification of antiepileptic drugs (AEDs) during VNS treatment could explain the improvement in patients. METHODS: We retrospectively assessed the efficacy of VNS in 30 adult patients with epilepsy treated with >6 months of follow-up. The criteria for implantation were the following: (1) not a candidate for resective epilepsy surgery, (2) drug-resistant epilepsy, (3) impairment of quality of life, (4) no other option of treatment, and (5) patients with idiopathic generalized epilepsy who fail to be controlled with appropriate AEDs. We assessed sociodemographics, seizure etiology, seizure classification, and AEDs used during treatment with VNS. We assessed adverse effects and efficacy. Responder rate was defined as >50% seizure improvement from baseline. RESULTS: Thirty patients (females, 18; males, 12; age, 35.1±13.3 years) were included. After 6, 12, 24, and 36 months of follow-up, the response rates were: 13/30 (43%), 13/27 (48%), 9/22 (41%), and 8/16 (50%), respectively; none was seizure free. Fifty-seven percent, 33%, 59%, and 81% of patients had changes of medication type or dose at 6, 12, 24, and 36 months respectively. In the majority of patients, the change of medication consisted of an increase in the dose of AEDs. CONCLUSIONS: Our study shows that VNS is an effective therapy, although significant changes in medications were done along with the therapy; therefore, the real effect of VNS could be controversial.

Pediatric thalamic tumors in the MRI era: a Canadian perspective.

BACKGROUND: Thalamic gliomas are rare. The natural history is unpredictable, and the optimal management of these tumors in children is poorly defined. The aim was to identify outcomes, prognostic factors, and response to various modalities of treatment in a relatively large population of pediatric thalamic tumors from many centers within a fairly homogeneous health care system. METHODS: We performed a Canadian multicenter retrospective review of pediatric thalamic tumors presenting during the MRI era (1989-2012). Radiology and pathology were reviewed by central independent reviewers. Paraffin shavings for RNA extraction were taken and tested for fusion events involving KIAA1549:BRAF. Tumors were classified as unilateral or bithalamic based on their origin on imaging. Univariate and multivariate analyses on factors influencing survival were performed. RESULTS: Seventy-two thalamic tumors were identified from 11 institutions. Females represented 53% of the study population, and the mean age at presentation was 8.9 years. Sixty-two tumors were unilateral and 10 bithalamic. Unilateral tumors had a greater propensity to grow inferiorly towards the brainstem. These tumors were predominantly low grade in comparison to bithalamic tumors which were high-grade astrocytomas. The 5-year overall survival was 61 ± 13% for unithalamic tumors compared to 37 ± 32% for bithalamic tumors (p = 0.097). Multivariate analysis indicated tumor grade as the only significant prognostic factor for unithalamic tumors. Six unilateral tumors, all low grade, were BRAF fusion positive. CONCLUSION: Unilateral and bilateral thalamic tumors behave differently. Surgical resection is an appropriate treatment option in unilateral tumors, most of which are low grade, but outcome is not related to extent of resection (EOR). Bilateral thalamic tumors have a poorer prognosis, but the occasional patient does remarkably well. The efficacy of chemotherapy and radiotherapy has not been clearly demonstrated. Novel therapeutic approaches are required to improve the prognosis for malignant unilateral thalamic tumors and bilateral thalamic tumors.

Biomolecular diagnosis of human glioblastoma multiforme using Synchrotron mid-infrared spectromicroscopy.

Glioblastoma multiforme (GBM) is one of the most malignant human tumors, with a uniformly poor outcome. One obstacle in curing malignant brain tumors is the limitation of conventional light microscopy in detecting microscopic residual tumor in biopsy samples from the perimeter of the surgically resected tumor. We further refined the identification of GBM tumor tissue at the sub-cellular level, utilising the technique of Synchrotron, sourced mid-infrared (mid-IR) spectromicroscopy. Paired, thin (5 microm) cryosections of snap-frozen human GBM tumor samples removed at elective surgery were mounted on glass slides (hematoxylin and eosin-stained tissue section) and calcium fluoride (CaF2) windows (unstained tissue section for transmission spectromicroscopy), respectively. Concordance of tumor bearing areas identified in the stained section with the unstained IR tissue section was confirmed by the pathologist of the study. Compared with molecular signatures obtained from normal control brain tissue, unique spectroscopic patterns were detected in GBM tumor samples from 6 patients. The identifying features of GBM were: i) high protein-to-lipid ratios (amide I+II/CH2 symmetric stretch; amide I+II/CH2+CH3 symmetric and asymmetric stretch), and ii) considerable enhancement of the intensities of characteristic peaks at 2,957 and 2,871 cm(-1) representing CH3 asymmetric and symmetric stretch, respectively. Spectral data sets were subjected to Ward's algorithm for assignment to similar groups, and then subjected to hierarchical cluster analysis (HCA) by means of false color digital maps. False color images of 5 clusters obtained by HCA identified dominant clusters corresponding to tumor tissue. Corroboration of these findings in a larger number of GBM may allow for more precise identification of these and other types of brain tumors.

Thalamic stimulation in multiple sclerosis: evidence for a 'demyelinative thalamotomy'.

The mechanism of action of deep brain stimulation (DBS) in the alleviation of tremor in multiple sclerosis (MS) and other neurological disorders is unknown. Moreover, whether the trauma accompanying this surgery is responsible for the induction of new MS plaques is controversial. Here we report the first description of the post-mortem imaging and pathologic findings in the brain of a MS patient who underwent thalamic DBS for the treatment of MS-induced tremor. MR imaging of formalin-fixed brain slices was carried out at 1.5, 3 and 7 Tesla and correlated with the histopathology. There were numerous demyelinative plaques in the white mater, cortex and deep gray matter. There were no plaques along the DBS tract within the sections that sampled the deep hemispheric white matter. However, deep within the thalamus focal demyelination approximated the tract, particularly in the region corresponding to the electrical field. The findings in this single case raise the possibility that focal demyelination may be induced by the electrical field and this may be responsible for long-lasting alleviation of tremor in the absence of continued electrostimulation.

Metastatic craniopharyngioma: case report and literature review.

BACKGROUND: Distant spread of craniopharyngioma is a rare but important complication. Most cases are a result of spread along the surgical path. We describe a rare case of metastatic leptomeningeal craniopharyngioma as a result of dissemination along CSF pathways in a child. A review of previously described cases is provided. CASE PRESENTATION: A 14-year-old male was diagnosed with metastatic craniopharyngioma on routine follow-up imaging after multiple surgeries and radiation for locally recurrent craniopharyngioma. The lesion was erosive through the right parietal bone, but had remained clinically silent. The lesion was distant from previous surgical paths. The patient underwent right parietal craniotomy and resection of the lesion. Duraplasty and cranioplasty were necessary for closure. Histopathology confirmed adamantinomatous craniopharyngioma. One-year follow-up demonstrated no recurrence. DISCUSSION: A review of reported cases suggests that leptomeningeal implantation may be an important step in metastases of craniopharyngioma, although the mechanism is poorly understood. Attention to tumor spillage at the time of surgery may be important in preventing distant recurrences.

Resolution of syringomyelia and Chiari malformation after growth hormone therapy.

INTRODUCTION: The association between hypopituitarism, Chiari I malformation, and syringomyelia has been recently recognized. Most of the reported patients suffered perinatal injury or asphyxia. MATERIALS AND METHODS: We present the case of a premature child without identifiable perinatal injury, who was recognized to have growth hormone (GH) deficiency, Chiari I malformation, and syringohydromyelia. CONCLUSION: There was a resolution of syrinx and tonsillar herniation after GH replacement.

Acquired encephalocele attributable to tuberculous osteitis: case report.

OBJECTIVE: There are many forms of calvarial tuberculosis. In this case report, extensive calvarial tuberculosis caused a large cranial defect and occlusion of the sigmoid sinus in a 10-year-old child. This resulted in a transient increase of the intracranial pressure and formation of an acquired encephalocele. CLINICAL PRESENTATION: A 10-year-old boy presented with an acquired, infected encephalocele and features of tuberculous mastoiditis. Computed tomographic and magnetic resonance imaging scans demonstrated evidence of left occipital encephalocele with left mastoiditis, extradural granulations, bone destruction, and complete occlusion of the left sigmoid sinus. INTERVENTION: The encephalocele was surgically excised and combined with left mastoidectomy. Although no mycobacterium had been demonstrated in the excised lesion, the presence of active tuberculous infection in the mastoid led to the conclusion that the bone destruction leading to encephalocele was secondary to the calvarial tuberculosis. The patient received antituberculous treatment with clinical improvement. CONCLUSION: This is the first report of calvarial tuberculosis causing a cranial defect and venous sinus thrombosis and resulting in an acquired encephalocele. Surgical excision combined with medical treatment was curative.

Multiple intracranial tumors in Philadelphia chromosome positive acute lymphoblastic leukemia: successful treatment following aggressive supportive care, early cranial radiation, high dose chemotherapy and imatinib.

We report the first case of multiple intracranial tumors ("chloromas") at diagnosis of Philadelphia chromosome positive acute lymphoblastic leukemia. The patient presented comatose with signs of cerebral herniation. Initial management of raised intracranial pressure and hyperleukocytosis followed by emergent whole brain radiation therapy reversed the life-threatening neurological signs. High-dose chemotherapy combined with daily imatinib mesylate induced a rapid and sustained bone marrow remission. Ongoing rehabilitation resulted in a near complete neurological recovery within 6 months of diagnosis. This outcome justifies aggressive early management of increased intracranial pressure and hyperleukocytosis in future similar presentations.

Depressed skull fracture and epidural hematoma from head fixation with pins for craniotomy in children.

OBJECTIVE: A head fixation device with pins is commonly used for immobilization of the patient's head during craniotomy. The safety of head fixation devices in children has been discussed rarely in the literature. The purpose of this report is to review our experience with complications of head fixation with pins in children undergoing craniotomies and to review the literature on this subject. MATERIALS AND METHODS: The database of the Division of Neurosurgery was reviewed to identify children who had cranial complications related to the use of a pin head fixation device. The charts of these patients were reviewed retrospectively. RESULTS: Five of 766 children (0.65%) undergoing craniotomies with pin fixation of the head had depressed skull fractures and/or epidural hematomas from the pin fixation. Age ranged from 2.6 to 7.5 years; all fractures were temporal and occurred during posterior fossa craniotomies. CONCLUSIONS: Depressed skull fractures and associated epidural hematomas need to be considered as possible complications of pin fixation of the head for craniotomy in young children.

Brown-Sèquard syndrome produced by C3-C4 cervical disc herniation: a case report and review of the literature.

STUDY DESIGN: The article presents a case in which Brown-Sèquard syndrome resulted from a painless C3-C4 disc herniation. OBJECTIVE: To raise spinal surgeons' awareness of this unusual clinical problem. SUMMARY OF BACKGROUND DATA: Brown-Sèquard syndrome involves ipsilateral loss of motor function combined with contralateral loss of pain and temperature sensation. Brown-Sèquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely it can be caused by a herniated cervical disc. METHODS: A 46-year-old man presented with progressive numbness and weakness in the left arm, mild neck pain, and reduced temperature sensation on the right side of the body. There was weakness in left arm and leg and proximal right lower limb. Magnetic resonance imaging showed large C3-C4 disc herniation compressing the spinal cord at that level. Anterior cervical discectomy and fusion with iliac crest bone graft was performed. RESULTS: Follow-up showed complete resolution of the neck pain, normal sensory function, and complete recovery of motor power in the left upper and right lower limb. There was a slight residual weakness in the left leg. CONCLUSION: Brown-Sèquard syndrome is rarely caused by a cervical disc herniation. This etiology may be underdiagnosed but has a more favorable outcome in those cases where rapid diagnosis is followed by spinal cord decompression.