儿童后颅窝肿瘤手术入路及骨瓣复位

目的：根据后颅窝肿瘤不同部位选择最佳手术入路。后颅窝开颅术改咬骨窗为开骨瓣。方法：蚓部肿瘤选择后颅窝正中入路。小脑半球肿瘤行正中钩形切口，肿瘤偏外选择外侧钩形切口。上蚓部肿瘤选择Ｐｏｐｐｅｎ入路。三种骨瓣：正中骨瓣、单侧骨瓣、单侧跨中线骨瓣。术毕骨瓣复位。结果：实施３８例儿童后颅窝肿瘤全切除术，髓母细胞瘤２３例，星形细胞瘤１０例，室管膜瘤３例，血管母细胞瘤１例，脑脓肿１例。无皮下积液发生，３例术后１０天内发烧。结论：后颅窝开骨瓣术、硬膜缝合、骨瓣复位符合解剖复位原则，术后并发症少，避免了因颅骨缺损造成的对儿童心理发育的不良影响     

Acquired torticollis as the only presenting symptom in children with posterior fossa tumors

Acquired torticollis is a symptom of an underlying disorder. It requires a thorough, meticulous search for the cause, because some of the problems associated with torticollis, such as posterior fossa tumor, can be life-threatening.     

Tonsillar herniation and cervical syringomyelia in association with posterior fossa tumors in children: a case-based update

Background Posterior fossa tumors most commonly occur in children. They frequently present with raised intracranial pressure and may have tonsillar herniation. The symptomatology is predominantly directed towards the tumor. The occurrence of syringomyelia in such cases is most unusual. Symptomatic syringomyelia is rare.Case report We describe a case of a pilocytic astrocytoma of the cerebellum in a 13-year-old girl who presented with clinical features of progressively worsening raised intracranial pressure and secondary tonsillar herniation and cervical syringomyelia. Magnetic resonance (MR) imaging showed a large midline inhomogenously enhancing vermian tumor causing moderate obstructive hydrocephalus. In addition, the cerebellar tonsils herniated down to the C2 level, and there was a centrally located syrinx from C2–T1. The tumor was resected through a suboccipital craniectomy. At follow-up after 3 months, MR imaging demonstrated total resolution of tonsillar herniation and cervical syringomyelia.Conclusions The occurrence of tonsillar herniation and syringomyelia in association with a slow growing benign tumor like pilocytic astrocytoma of the cerebellum is uncommon. The blockade of normal cerebrospinal fluid circulation pathway at the foramen magnum is the crucial factor. Surgical extirpation of the tumor restores the normal cerebrospinal fluid circulation at the foramen magnum and produces an excellent outcome. The need for an additional surgical procedure for treatment of associated tonsillar herniation and syringomyelia can be avoided. Volumetric assessment of the posterior fossa may provide a better understanding of the pathophysiology of syringomyelia in such patients.     

Transient mutism following a posterior fossa approach to cerebellar tumors in children: a critical review of the literature

Transient mutism has been known as a rare complication following a posterior fossa approach to cerebellar tumors and its cause has not been clearly elucidated. The cerebellar mutism is not accompanied by cranial nerve deficits and disorders of consciousness. Since 1985 only 23 cases of mutism following removal of a cerebellar tumor in children have been reported in the literature. Two additional cases have been operated upon in our department. Extensive injury to the vermian and paravermian cerebellar area, involving the hemispheric cortex, cerebellar peduncles, fibers from the dentato-thalamocortical pathway, and dentate and interpositum nuclei may be the most important anatomical substrate of mutism. The mechanism of such transient mutism seems to be a complex of two or more factors (vascular disturbances due to manipulation or retraction of the cerebellar region around the IV ventricle and emotional factors). On the basis of these 25 cases the major features of the cerebellar mutism are discussed.     

Use of a ventriculosubgaleal shunt in the management of hydrocephalus in children with posterior fossa tumors

We present our experience with the use of ventriculosubgaleal shunting (VSGS) for the management of hydrocephalus associated with posterior fossa tumors in a consecutive series of 63 children. In 42 children, a temporary VSGS was inserted. There were no complications associated with the procedure, and it gave a period of several days in which to improve the general condition of the child, and to perform the necessary imaging studies, without an encumbering external drainage device. In most cases the VSGS could be removed after the posterior fossa surgery, without new general anesthesia. Other advantages and drawbacks of this technique are discussed.     

Hydrocephalus in posterior fossa tumors in children. Are there factors that determine a need for permanent cerebrospinal fluid diversion?

Objective  We searched for factors that could predispose towards persistent hydrocephalus in children with posterior fossa (PF) tumors in order to determine the need for permanent cerebrospinal fluid (CSF) diversion. Methods  The clinical records of 64 children who underwent surgery for PF tumors in the Pediatric Neurosurgery division of the Hospital of Clinics, Ribeirao Preto, Brazil, from 1990 to 2006, were retrospectively reviewed. The patients’ ages ranged from 3 months to 18 years. The factors evaluated included age at surgery, severity of hydrocephalus (ventricular index), tumor location, size of the tumor, extent of tumor resection, and histology. Results  Ventricular index, measured from the initial neuroradiological image, age at surgery, and location of the tumor were significantly associated with definitive postoperative CSF diversion (shunt or endoscopic third ventriculostomy), which was necessary for 34% of the patients. Conclusions  Young children with severe preoperative hydrocephalus and a midline tumor should be considered at risk when preoperative treatment decisions are made.     

儿童后颅窝病变术后皮下积液的成因及防治

目的 探索儿童后颅窝病变术后皮下积液的原因及防治措施.方法 回顾性分析34例儿童后颅窝病变行手术切除患者的临床资料.结果 34例中有8例发生术后皮下积液,其中术中未严密缝合硬脑膜(6/12)及合并术后脑积水者(4/6)显著高于严密缝合硬脑膜(2/22)与未发生脑积水者(4/28)(P＜0.05);术中未行骨瓣复位者(4/11)有高于骨瓣复位者(4/23)的趋势,但差异无统计学意义(P＞0.05).是否放置术腔外引流与皮下积液的发生无明显关系(P＞0.05).结论 儿童后颅窝病变术后皮下积液的形成与术中未严密缝合硬脑膜及术后并发脑积水关系密切,其防治有赖于针对上述环节的妥善处理.     

Posterior fossa tumors in children: how long does it take to establish the diagnosis?

Objective The aim of this study is to evaluate, for our patient population, the time interval from the first chart-documented symptom to the radiological diagnosis in children and infants with posterior fossa tumors. Materials and methods We retrospectively analyzed 50 consecutive children (36 men, 14 women) with posterior fossa tumor treated at our department between January 1999 and December 2003. The mean age at time of diagnosis was 98 months (6 months–16 years). The mean follow up was 27 months (6–61 months). The diagnoses included astrocytoma (n = 17), medulloblastoma (n = 15), ependymoma (n = 6), and other tumors (n = 12). Results The mean time interval between onset of symptoms and radiographic diagnosis was 142 days (5–535 days), the median was 59 days. The mean time for Grade I and II tumors was 238 days (n = 19) and for tumors Grade III and IV 117 days (n = 31). The most common presenting symptoms were headache, nausea, vomiting, ataxia, and oculomotor deficits. Approximately half of the patients were initially diagnosed and treated for other diseases (gastrointestinal infection, appendicitis, psychological behavioral problems, cervical spine strains, different ophthalmologic entities). Specialists (ophthalmologists, orthopedics) tended to diagnose and treat their specific diagnoses (e.g., strabism, torticollis). Parents play a significant role in the process of establishing the correct diagnosis. Conclusion We conclude that further information and education regarding symptomatology and diagnosis of posterior fossa tumors in children is necessary. Communication has to be improved between parents and referring physicians of all specialties and neurosurgeons.     

儿童后颅窝肿瘤合并脑积水的治疗及预后影响因素分析

目的 探讨儿童后颅窝肿瘤合并脑积水患者行肿瘤切除术前对于脑积水的治疗是否影响术后脑积水的发生率,并分析术后脑积水发生的相关危险因素.方法 中山大学附属第一医院神经外科自2003年1月至2009年12月行肿瘤切除术治疗后颅窝肿瘤合并脑积水儿童患者63例,其中对术前脑积水行保守治疗43例,手术治疗20例.回顾性分析患者的临床资料并比较术前脑积水保守治疗组和手术治疗组患者术后脑积水的发生率,Logistic回归分析患者的性别、发病年龄、术前Evans指数、肿瘤病理类型、肿瘤切除程度、肿瘤生长部位等因素是否与术后脑积水的发生有关.结果 术后出现脑积水患者22例,其中术前脑积水保守治疗组14例(14/43,32.6%),术前脑积水手术治疗组8例(8/20,40.0%),2组比较脑积水发生率差异无统计学意义(P=0.564);Logistic 回归分析发现患者术前Evans指数、肿瘤生长部位、肿瘤切除程度与肿瘤切除术后脑积水的发生有关(P=0.029,p=0.036,P=0.038).结论 肿瘤切除术前脑积水的治疗并不能改变术后脑积水的发生率:术前Evans指数、肿瘤生长部位、肿瘤切除程度是肿瘤切除术后脑积水发生的危险因素.

Abstract：

Objective To explore whether preoperative treatment of hydrocephalus could change the occurrence of postoperative hydrocephalus after tumor resection in children with posterior fossa tumor, and analyze the risk factors of postoperative hydrocephalus. Methods Sixty-three children with posterior fossa tumors accompanied with hydrocephalus, admitted to our hospital from January 2003 to December 2009, were chosen; conservative treatment of preoperative hydrocephalus was performed in 43 patients and surgery was performed in the other 20 patients. The clinical data of these patients were retrospectively analyzed and the occurrence of postoperative hydrocephalus in patients performed conservative treatment and tumor resection was compared. Gender, age, Evans index, location of the tumor, extent of the tumor resection, pathology of the tumor were analyzed as risk factors using logistic regression. Results Occurrence of hydrocephalus after tumor resection showed no statistical differences between patients accepted conservative treatment (14/43, 32.6%) and patients received surgical treatment ([8/20, 40.0%], P=0.564). Evans index, location of the tumor and extent of resection were related to hydrocephalus relapse after tumor resection(P=0.029, P=0.036, P=0.038). Conclusion Preoperative treatment of hydrocephalus could not change the occurrence of hydrocephalus after tumor resection. Evans index, location of the tumor and extent of tumor resection are all risk factors of postoperative hydrocephalus.     

颅后窝手术后感染原因分析及治疗

目的对颅后窝术后感染原因分析,为减少颅后窝手术后感染以及提高疗效提供一定的借鉴。方法对发生颅后窝术后颅内感染28例进行细菌培养,并运用敏感抗生素加腰穿置管持续脑脊液引流,部分病例进行小剂量抗生素鞘内注射。结果感染得到有效控制,患者痊愈者27例,占96.4%。1例患者因感染未能控制,最终全身衰竭死亡。结论颅后窝手术因有较多易致感染因素,较其他开颅手术更易导致术后感染。手术中严格无菌操作,缩短手术时间,减少明胶海绵、止血纱以及人工植入物的放置,严密缝合伤口,减少局部积液及脑脊液漏的发生等能减少术后感染的发生。正确应用抗生素,腰穿置管引流、鞘内注射抗生素等对控制颅内感染效果较好。     

Postoperative swallowing function after posterior fossa tumor resection in pediatric patients

Objective After tumor resection involving the posterior fossa, postoperative swallowing dysfunction may be anticipated. This retrospective study was designed to document swallowing abnormalities in children after posterior fossa brain tumor surgery and to recommend management approaches for children at risk for aspiration.Methods Twenty-four children referred postoperatively for a video fluoroscopic swallow study (VFSS) out of 127 children undergoing posterior fossa surgery for brain tumor resection from 1998 to 2001 were evaluated for oral, pharyngeal, and cervical esophageal transits.Conclusion Less than half of the 24 children swallowed functionally within the first week after surgery. VFSS was an appropriate tool for diagnosing swallowing dysfunction, which is impossible to determine at bedside. Children with brain stem involvement and more difficult recovery had significantly worse swallowing function and greater aspiration. We recommend that children with compromised swallowing function should not feed orally until a radiographic swallowing assessment demonstrates functional and safe swallowing with or without therapeutic intervention.     

Incidence of spinal deformity in children after multiple level laminectomy for selective posterior rhizotomy

Fifty-five children with cerebral palsy had multiple-level laminectomies for selective posterior rhizotomies for the relief of spasticity. They were followed up clinically and radiologically to assess their spinal stability and the possible development of post-laminectomy deformity of the spine. The majority of the deformities found were related to cerebral palsy and did not appear to be due to the laminectomy: 16% had scoliosis, 5% kyphosis, 7% lordosis, and 9% spondylolysis/spondylolisthesis. Spondylolysis is the only abnormality that appeared to be more common in this group than in children with cerebral palsy.     

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

Objective The 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 methods A 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. Results Out 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. Conclusion In 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. A commentary on this paper is available at .     

Traumatic extradural hematomas of the posterior fossa in children

The most favorable type of traumatic intracranial bleeding in childhood is the extradural hemorrage (EDH). The posterior fossa location is less frequent than the supratentorial site. In the period from January 1989 to January 1994 we treated 2,372 patients with craniocerebral trauma; 31 had extradural hematomas (1.3%); 3 of them were located in the posterior fossa (9.7%): 1 boy and 2 girls aged from 6 to 16 years. The traumatic mechanism was an occipital fall in all cases. Diagnosis was made by computed tomography scan (CT). Two of them had a rapidly deteriorating course. The three patients were operated on without mortality and there was no morbidity. The role of CT in the early detection of lesions and prompt surgical evacuation may reduce the mortality and morbidity from this lesion. The interaction between these factors is discussed.     

Posterior fossa tumors in children: Radiological tips & tricks in the age of genomic tumor classification and advance MR technology

Imaging plays a major role in the comprehensive assessment of posterior fossa tumor in children (PFTC). The objective is to propose a global method relying on the combined analysis of radiological, clinical and epidemiological criteria, (taking into account the child's age and the topography of the lesion) in order to improve our histological approach in imaging, helping the management and approach for surgeons in providing information to the patients’ parents. Infratentorial tumors are the most frequent in children, representing mainly medulloblastoma, pilocytic astrocytoma and brainstem glioma. Pre-surgical identification of the tumor type and its aggressiveness could be improved by the combined analysis of key imaging features with epidemiologic data.     

Posterior fossa tumors in children – indications for ventricular drainage and for V-P shunting

A clinical analysis of 95 patients with posterior fossa tumors treated in the Department of Neurosurgery of the Medical University in Gdansk over a period of 16 years (1979–1995) is presented. The following preoperative factors were studied: localization, size and suspected type of tumor, size of the ventricular system, and presence or absence of the “halo” symptom. The indications for ventricular drainage (Fisher) versus V-P shunting as a preliminary treatment are discussed. Finally, the advantages of each of these procedures are emphasized. Received: 19 December 1997     

小儿后颅窝囊肿特点和治疗探讨

目的探讨小儿后颅窝囊肿的临床特点、手术方式及疗效。方法回顾分析近10年内治疗的38例后颅窝囊肿病变患儿的临床资料。这38例患儿中行单纯囊肿一腹腔分流治疗13例，囊肿剥离开窗治疗14例（其中显微镜下剥离13例，内镜下剥离1例），神经内镜辅助下第三脑室底造瘘术结合分流术或囊肿剥离开窗治疗（联合手术组）11例（均为巨大囊肿合并脑积水者）。结果分流组再次手术率15．4％（2113），囊肿剥离开窗组再次手术率7．1％（1／14），联合手术组再手术率18．2％（2111）。术后平均随访3年以上，所有病人的囊肿均缩小。结论对小儿后颅窝囊肿治疗应根据囊肿部位、大小和脑脊液吸收功能情况制定以显微镜下囊肿剥离术为首选，配合内镜和分流术的个体化手术方案。     

Reversible cerebral perfusion alterations in children with transient mutism after posterior fossa surgery

Mutism is an infrequent and transitory complication observed following posterior fossa surgery. Patients become mute in the immediate postoperative period, with restoration of speech within a few weeks in the absence of additional neurological alterations. The anatomical structures thought to be involved are the connections between the cerebellar dentate nucleus, the ventrolateral nucleus of the contralateral thalamus and the supplementary motor area. In an attempt to understand the pathophysiology of this syndrome, and to depict the perfusion of different brain areas semiquantitatively, in two children who had become mute after posterior fossa surgery we performed a Tc99M-HM-PAO SPECT study during the period of mutism and again when normal speech had returned. In one patient, who had a left cerebellar astrocytoma, the SPECT study showed a marked reduction of cerebral perfusion in the right fronto-parietal region, and in the other, who had a medulloblastoma, a left fronto-temporo-parietal perfusion alteration was observed. When the patients regained normal speech, the follow-up SPECT studies revealed normalization of the cerebral perfusion. This study demonstrates the occurrence of a focal dysfunction of cerebral perfusion in children with cerebellar mutism after posterior fossa surgery. These observations are useful in extending our understanding of the pathophysiology of this postoperative clinical syndrome. Received: 12 September 1997 Revised: 17 November 1997     

Cervical spine instability following cervical laminectomies for Chiari II malformation: a retrospective cohort study

Objective  The treatment of symptomatic Chiari II malformations typically involves multilevel cervical laminectomies in very young children. These patients are at significant risk of cervical instability. The purpose of this study was to determine the incidence and significance of cervical instability after multilevel cervical laminectomies in a cohort of patients decompressed for Chiari II malformation. Methods  Postoperative dynamic lateral cervical spine radiographs were obtained on pediatric patients who had multilevel cervical laminectomies for symptomatic Chiari II malformations. Postoperative cervical spine instability was determined radiographically using published criteria. Clinical instability and need for cervical fusion were also assessed. Results  Nine patients met inclusion criteria for the study. Five of the nine patients (56%) showed evidence of radiographic instability of their cervical spines following surgery for their Chiari II malformations, according to the criteria used. No patient showed evidence of clinical instability or required cervical fusion. Conclusion  Radiographic evidence of cervical spine instability following multilevel cervical laminectomies for Chiari II is common but may be of minimal clinical significance. The reason for the lack of clinical instability in what might be considered high-risk patients is not understood.     

Postoperative antibiotic management strategy for febrile patient with posterior cranial fossa tumor resection: Retrospective clinical study

ObjectivePostoperative fever (POF), associated with posterior cranial fossa (PCF) surgery, occurs commonly and is a potential intracranial infection indicator of perioperative antibiotics prolongation and advancement. The existing prophylactic approaches to balancing the risk between intracranial infection and antibiotics abuse are debatable.MethodsWe retrospectively assessed 100 patients subjected to PCF tumor resection between December 2015 and December 2018 at a single institution. Forty febrile patients were selected for further analysis. Of them, 16 received basic and 24 advanced antibiotics and were subjected to prophylactic antibiotic assessment.ResultsThe total POF rate of PCF tumor resection was 49.4%. POF occurred from day 1 to day 5, along with the abnormalities of cerebrospinal fluid (CSF) profiles and the mild meningeal irritation symptom. CSF cultures of all selected patients were negative. In the comparison between the basic and advanced antibiotic therapy, we found no statistically significant differences in the results of the average and dynamic analysis of the body temperature and CSF profiles. Negative results of outcome studies were also obtained in the duration of fever, duration of hospitalization, and total hospitalization expenses. However, the expenses were substantially increased in the advanced antibiotic treatment.ConclusionsAlthough POF is a common symptom after PCF tumor resection, definite intracranial infection is rare. A high body temperature and significant abnormal CSF profiles at an early stage may not be a specific and sufficient indicator of intracranial infection to upgrade antibiotics therapy when standard prophylactic protocols have been accurately achieved.