Solitary Langerhans cell histocytosis of skull and spine in pediatric and adult patients

Purpose

Langerhans cell histiocytosis (LCH) is a rare neoplasm and has heterogeneous clinical presentation and behavior. We analyzed solitary lytic lesions of the skull and spine in pediatric and adult patients.

Methods

Between 2001 and 2011, 42 patients underwent surgery for LCH. Skull and/or spine involvement were evident in 21 (63.6 %) of the 33 pediatric patients and 8 (88.9 %) of the 9 adults. The 21 pediatric patients showed the unifocal monosystemic lesions in 10, multifocal monosystemic in 4, and multisystemic in 7. The eight adults comprised seven unifocal lesions and one multifocal monosystemic lesion. Of these cases, we analyzed the clinical courses of solitary LCH of skull and spine in 10 pediatric patients and 7 adults.

Results

The median age was 10.1 years (range: 1.1–14.1) in pediatric patients and 34.6 years (range: 26.1–52.0) in adults. The median follow-up was 3.1 years (range: 0.6–9.5). Total excision was done in 15 patients and biopsy in 2. Postoperative adjuvant chemotherapy was done in four pediatric patients and one adult, and comprised mass with dural adhesion (N?=?2), skull base lesion (N?=?1), atlas mass (N?=?1), and vertebral lesion with soft tissue extension (N?=?1). During follow-up, recurrence occurred in one pediatric patient who had a skull LCH with a dural adhesion. The patient experienced central diabetes insipidus and scapular pain due to pituitary stalk and scapula involvement 1.3 and 2.4 years later, respectively.

Conclusion

Even if the solitary lesions of skull and spine show a favorable clinical course, some patients could show aggressive behavior.     

Awake surgery for hemispheric low-grade gliomas: oncological,functional and methodological differences between pediatric and adult populations

Introduction

Brain mapping through a direct cortical and subcortical electrical stimulation during an awake craniotomy has gained an increasing popularity as a powerful tool to prevent neurological deficit while increasing extent of resection of hemispheric diffuse low-grade gliomas in adults. However, few case reports or very limited series of awake surgery in children are currently available in the literature.

Methods

In this paper, we review the oncological and functional differences between pediatric and adult populations, and the methodological specificities that may limit the use of awake mapping in pediatric low-grade glioma surgery.

Results

This could be explained by the fact that pediatric low-grade gliomas have a different epidemiology and biologic behavior in comparison to adults, with pilocytic astrocytomas (WHO grade I glioma) as the most frequent histotype, and with WHO grade II gliomas less prone to anaplastic transformation than their adult counterparts. In addition, aside from the issue of poor collaboration of younger children under 10 years of age, some anatomical and functional peculiarities of children developing brain (cortical and subcortical myelination, maturation of neural networks and of specialized cortical areas) can influence direct electrical stimulation methodology and sensitivity, limiting its use in children.

Conclusions

Therefore, even though awake procedure with cortical and axonal stimulation mapping can be adapted in a specific subgroup of children with a diffuse glioma from the age of 10 years, only few pediatric patients are nonetheless candidates for awake brain surgery.

     

Harvey Cushing��s early experience with pediatric gliomas

Purpose

Diagnosing and operating pediatric patients with intracranial lesions posed a greater diagnostic challenge for physicians during the early twentieth century. At the time, an intracranial neoplasm was indistinctively diagnosed as a glioma, encompassing a broad category of brain tumor pathologies. The treatment and surgical interventions followed for children diagnosed with gliomas is not well-described in the literature from this time.

Methods

Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896?C1912. Patients 18?years or younger, who underwent surgical intervention by Cushing for suspected intracranial tumors, were selected.

Results

Of the eight pediatric cases diagnosed with gliomas by Cushing, four cases were later diagnosed as medulloblastomas by Dr. Cushing in 1925. Of the remaining four pediatric cases, one was diagnosed as a brainstem glioma and another as a ventricular glioma. We describe the remaining two cases.

Conclusion

These examples illustrate Cushing??s approach to treating brain tumors diagnosed as gliomas in pediatric patients, focusing on an initial decompression and followed by a thorough surgical exploration for tumor. Furthermore, these cases demonstrate Cushing??s early attempts to manage such lesions in children and highlight the challenges faced in diagnosing and localizing intracranial lesions within this group of patients.     

The use of 5-aminolevulinic acid fluorescence guidance in resection of pediatric brain tumors

Introduction

Whereas in the adult population 5-Aminolevulinic acid (5-ALA) fluorescence guidance has been widely accepted for improving the extent of tumor resection, the application in children remains an off-label use. Even though most pediatric study protocols require a complete resection for improving outcome parameters, only few pediatric patients have been operated with fluorescence guidance, and it remains questionable, whether and which pediatric tumors show useful fluorescence. We present casuistic reports of application of 5-ALA in children collected from three different neurosurgical departments.

Patients and methods

In children with suspected malignant intracerebral tumor or recurrence, individual informed consent was obtained in each case from the parents. 5-ALA was administered according to the adult protocol, with 20 mg/kg, 2 h before induction of anesthesia. We retrospectively analyzed 18 patients (13 male, 5 female; age 3–18 years), using the intraoperative neurosurgical protocol, the postoperative MRI results, and the follow-up clinical examinations.

Results

The use of 5-ALA fluorescence guidance proved to be safe in our group of pediatric patients. Fluorescence guidance was most useful for recurrent glioblastoma resection. Medulloblastoma tissue displayed fluorescence only inconsistently, and most pilocytic astrocytoma remained without staining. Ganglioglioma showed partial staining in the central tumor areas, without allowing the use for circumferent resection.

Conclusion

The off-label use of 5-ALA fluorescence guidance in pediatric patients appears to be most useful in recurrent high-grade gliomas. Fluorescence accumulation in other pediatric brain tumor entities is not predictable and should be evaluated in future clinical studies before being integrated into the current treatment protocols.     

Regional Brain Injury on Conventional and Diffusion Weighted MRI is Associated with Outcome After Pediatric Cardiac Arrest

Background

To assess regional brain injury on magnetic resonance imaging (MRI) after pediatric cardiac arrest (CA) and to associate regional injury with patient outcome and effects of hypothermia therapy for neuroprotection.

Methods

We performed a retrospective chart review with prospective imaging analysis. Children between 1 week and 17 years of age who had a brain MRI in the first 2 weeks after CA without other acute brain injury between 2002 and 2008 were included. Brain MRI (1.5 T General Electric, Milwaukee, WI, USA) images were analyzed by 2 blinded neuroradiologists with adjudication; images were visually graded. Brain lobes, basal ganglia, thalamus, brain stem, and cerebellum were analyzed using T1, T2, and diffusion-weighted images (DWI).

Results

We examined 28 subjects with median age 1.9 years (IQR 0.4–13.0) and 19 (68 %) males. Increased intensity on T2 in the basal ganglia and restricted diffusion in the brain lobes were associated with unfavorable outcome (all P < 0.05). Therapeutic hypothermia had no effect on regional brain injury. Repeat brain MRI was infrequently performed but demonstrated evolution of lesions.

Conclusion

Children with lesions in the basal ganglia on conventional MRI and brain lobes on DWI within the first 2 weeks after CA represent a group with increased risk of poor outcome. These findings may be important for developing neuroprotective strategies based on regional brain injury and for evaluating response to therapy in interventional clinical trials.     

High-resolution 3-T MR imaging of the temporal part of the caudate tail in children

Background and purpose

This study aims to investigate the high-resolution 3-T MRI appearance and morphological variation of the temporal part of the caudate tail in pediatric subjects with normal brain MR examinations.

Patients and methods

One hundred pediatric patients were retrospectively evaluated using a high-resolution 3-T imaging protocol. Different morphological parameters including shape, size, and symmetry were evaluated. The appearance and shape of the caudate tail were classified into nodular, linear, or imperceptible. The location and relation of the caudate tail to the temporal horn and adjacent brain parenchyma were categorized. Relationships between age, gender, shape, location, side, and the cross-sectional area of the caudate tail were investigated.

Results

The caudate tail was imperceptible in 22 %, had a nodular shape in 66.5 %, and was flat in 11.5 %. There was asymmetry of the caudate tail between the two sides in 37 % of subjects. The caudate tail was completely embedded within the temporal lobe parenchyma in 8.3 %, completely protruding into the temporal horn in 27.5 %, or intermediate in 64.1 %. The mean cross-sectional area of the caudate tail was constant across ages despite the varied age range of the subjects. There was no difference in overall mean cross-sectional area of the caudate tail between the two sides.

Conclusion

There is a wide variation in the appearance of the caudate tail adjacent to the temporal horn of the lateral ventricle. Identification of anatomical variation of the caudate tail may prevent potential diagnostic pitfalls, especially with respect to subependymal heterotopia.     

Pediatric indications for deep brain stimulation

Purpose

Based on the success of deep brain stimulation (DBS) in the treatment of adult disorders, it is reasonable to assume that the application of DBS in the pediatric population is an emerging area worthy of study. The purpose of this paper is to outline the current movement disorder indications for DBS in the pediatric population, and to describe areas of investigation, including possible medically refractory psychiatric indications.

Methods

We performed a structured review of the English language literature from 1990 to 2011 related to studies of DBS in pediatrics using Medline and PubMed search results.

Results

Twenty-four reports of DBS in the pediatric population were found. Based on published data on the use of DBS for pediatric indications, there is a spectrum of clinical evidence for the use of DBS to treat different disorders. Dystonia, a disease associated with a low rate of remission and significant disability, is routinely treated with DBS and is currently the most promising pediatric application of DBS. We caution the application of DBS to conditions associated with a high remission rate later in adulthood, like obsessive-compulsive disorder and Tourette’s syndrome. Moreover, epilepsy and obesity are currently being investigated as indications for DBS in the adult population; however, both are associated with significant morbidity in pediatrics.

Conclusion

While currently dystonia is the most promising application of DBS in the pediatric population, multiple conditions currently being investigated in adults also afflict children and adolescents, and thus warrant further research.     

Intramedullary spinal cord cavernous malformations presenting with unexplained chest pain: case report and review of the literature

Introduction

Intramedullary spinal cord cavernous malformations are very uncommon in pediatric age, with only 26 cases reported within the available literature to date. The diagnosis of such lesions is often difficult and delayed because of their rarity and bizarre clinical presentation.

Case report

We report a case of intramedullary spinal cord cavernous malformation in a girl, in which sudden onset chest pain was the only presenting symptom, followed by appearance of neurological deficits after 5 days. We review the available literature discussing clinical features and principles of management of these lesions in children.     

Combined pre- and subtemporal transtentorial approach for epidermoid cysts of the cerebellopontine angle

Objective

Epidermoid cysts of the cerebellopontine angle (CPA) can be a surgical challenge for the pediatric neurosurgeon. Ideally, total removal must be achieved; however, occasional adhesions of these tumors to vital neurovascular structures and extension far beyond the midline may preclude their total removal. The aims of this article are to present an alternative surgical approach to these lesions and to provide the rationale for this technique.

Material and methods

A 16-year-old boy was admitted to our pediatric neurosurgery department with a 1-year history of nonspecific headaches. His neurological examination showed right-sided dysmetria and gait ataxia. Magnetic resonance scans showed a space-occupying lesion on the right CPA with low intensity on T₁-weighted images and high intensity on T₂-weighted images.

Results

Craniotomy for tumor excision via pre- and subtemporal transtentorial approach was performed disclosing a 3.5?×?3?×?2.8-cm³ well-encapsulated tumor, which was confirmed to be an epidermoid cyst. The postoperative course was uneventful.

Conclusions

A combined pre- and subtemporal approach utilizes a wide opening of the tentorium and the option of supratentorial retraction of the cerebellum to provide an excellent angle of approach to CPA lesions involving the anterolateral aspect of the brain stem in children.     

Cerebral Salt Wasting Syndrome in Post-Operative Pediatric Brain Tumor Patients

Background

Cerebral salt wasting syndrome (CSWS) and the syndrome of inappropriate antidiuretic hormone (SIADH) are both causes of hyponatremia in pediatric neurosurgical patients often with similar presenting symptoms; however, despite similar clinical characteristics the treatment for CSWS and SIADH can be drastically different, which makes the distinction critical for post-operative treatment. Further complicating matters, are the exact mechanism for CSWS which remains unclear, and the incidence and severity of CSWS is not well studied in pediatric neurosurgical patients. We hypothesized that CSWS occurs frequently in post-operative brain tumor patients and is an important cause of post-operative hyponatremia in these patients.

Methods

We designed a single institution retrospective cohort study of all pediatric brain tumor patients undergoing craniotomy for tumor resection at our institution between January 2005 and December 2009.

Results

Of the 282 patients undergoing 291 operations, post-operative CSWS was identified in 15 cases (5%), and was more frequently observed than SIADH (nine cases, 3%). Median onset of CSWS was on post-operative day 3, lasting a median of 2.5 days. Patients with CSWS were more likely to have suffered post-operative stroke (40 vs. 4.6%, P?<?0.001), have chiasmatic/hypothalamic tumors (40 vs. 3.8%, P?=?0.002), and be younger (mean age 5.9 vs. 9.7 years, P?=?0.01) than eunatremic patients. In addition, nearly half of the patients with CSWS (47%) had post-operative hyponatremic seizures.

Conclusion

The diagnosis of CSWS should be strongly considered in hyponatremic pediatric patients with significant natriuresis following brain tumor resection, and a treatment initiated promptly to prevent neurologic sequeleae.     

Primary gliomatosis cerebri involving gray matter in pediatrics: a distinct entity? A multicenter study of 14 cases

Background and purpose

Gliomatosis cerebri (GC) is a rare neoplasm including a variety of tumors, with extremely variable evolution and heterogeneity of prognosis. It may appear either de novo or after a focal glioma, involve predominantly the white or the gray matter, and concern either pediatric or adult patients. We focused on primary GC involving exclusively gray matter in a pediatric population in order better to define the presentation and outcome of this disease.

Patients and methods

We reviewed the databases of seven Departments of Pediatric Oncology to identify pediatric cases of GC between 1990 and 2007. Patients were included if they demonstrated a diffuse infiltrative process involving gray matter in magnetic resonance imaging (MRI) and histological tissue analyses, confirming a proliferative glial disorder.

Results

Fourteen patients with a median age of 8 years were identified. Epilepsy was the main presenting symptom. Brain MRI showed a lesion of the temporal and insular cerebral cortex associated with tumoral infiltration of the thalami and the basal ganglia. Histological examination confirmed the diagnosis of high-grade glioma. Prognosis was always very gloomy in the short term, with a median survival of less than a year.

Conclusion

This rare entity, whose prognosis is appalling whatever the treatment proposed, should be clearly identified within the heterogeneous group of GC in the same way as diffuse intrinsic pontine gliomas have been identified among brain stem tumors. Systematic biopsies appear essential to permit the molecular studies which will assist in guiding the choice of future targeted treatments.     

Embryonal tumor with abundant neuropil and true rosettes: an autopsy case-based update and review of the literature

Introduction

Embryonal tumor with abundant neuropil and true rosettes (ETANTR) is a rare subtype of primitive neuroectodermal tumors first reported in 2000. It is rare among the group of embryonal central nervous system tumors with approximately 50 reported cases. ETANTR has been suggested to be a separate entity among this group of tumors.

Case report

Herein, we present only the second autopsy case of ETANTR, which occurred in a 17-month-old boy, and was located in the brainstem. The tumor was inoperable, and despite chemotherapy, the child died 3 months after initial hospitalization. A brain only autopsy was performed.

Discussion

Neuropathological and neuroimaging examinations suggest ETANTR grew by expansion rather than invasion distorting anatomical structures of the posterior fossa. We suggest that the characteristic histopathological picture of the tumor is the result of multifocal and dispersed germinative activity surrounded by mature neuropil-like areas.

Conclusion

ETANTR is a pediatric tumor occurring in children under 4 with a significantly poor prognosis with more cases and research required to characterize this rare embryonal tumor.     

Suprasellar granular cell tumor of the neurohypophysis in a child: unusual presentation in pediatric age of a rare tumor

Purpose

Granular cell tumors (GCT) of the neurohypophysis are rare, solitary, nodular-shaped lesions, mostly presenting in the adult age with a female predilection. They rarely grow to a sufficient size to cause mass effect related symptoms and they may be found in most cases incidentally at autopsy of older patients. Few cases of symptomatic GCT of the neurohypophysis have been reported in the literature and only one of these in a pediatric patient in the first decade of life, who presented with central precocious puberty.

Methods

We report the case of a 11-year-old boy with a large suprasellar GCT of the neurohypophysis, complaining severe headache and pituitary insufficiency. Before our referral, the child was operated at another insitution through a pterional approach for tumor biopsy and underwent chemotherapy because of the misleading diagnosis of glioma.

Results

The patient was operated on by a fronto-orbito-zygomatic approach with subtotal tumor resection. At last follow-up examination, a partial hypopituitarism was detected. The quality of life with replacement therapy was excellent. Fractionated radiotherapy on tumor remnant was advised.

Conclusions

The reported case is exceptional because the tumor developed in a male pediatric patient, causing clinical symptoms related to intracranial hypertension and unusual endocrinological features. GCT has to be considered in the differential diagnosis of suprasellar masses, to avoid misleading interpretation and consequent wrong therapeutic management.     

Seizure and developmental outcomes after hemispherectomy in children and adolescents with intractable epilepsy

Purpose

The aim of this study is to describe a series of pediatric hemispherectomies, reviewing pathologic substrate, epilepsy characteristics and seizure outcome as well as developmental profiles, before and after surgery, in different domains.

Methods

Seventeen patients with full pre-surgical work-up, minimum follow-up of 12 months, and at least one post-surgical neuropsychological evaluation were selected. Three had Rasmussen encephalitis (RE), five hemispheric malformations of cortical development (MCD), and nine hemispheric vascular lesions.

Results

At latest follow-up, all patients with RE and 66.7 % of those with vascular lesions are in Engel’s class I; in the latter group, pre-surgical independent contralateral EEG discharges statistically correlated with a worse seizure outcome. Patients with MCD showed the worst seizure outcome. Pre-surgical language transfer to the right hemisphere was confirmed in a boy with left RE, operated on at 6 years of age. Patients with MCD and vascular lesions already showed severe global developmental delay before surgery, which persists afterwards. A linear correlation was found between earlier age at surgery and better outcome in personal–social, gross motor, and adaptive domains, in the vascular lesions group. The case with highest cognitive improvement had continuous spike and wave during sleep on pre-surgical EEG.

Conclusions

Pathologic substrate was the main factor related with seizure outcome. In children with MCD and vascular lesions, although developmental progression is apparent, significant post-surgical improvements are restricted by the severity of pre-surgical neuropsychological disturbances and a slow maturation. Early surgery assessment is recommended to enhance the possibilities for a better quality of life in terms of seizure control, as well as better autonomy and socialization.     

Perimedullary arteriovenous fistulas in pediatric patients: clinical, angiographical, and therapeutic experiences in a series of 19 cases

Objective

The objective of this study was to review our pediatric series of perimedullary arteriovenous fistula (PMAVF), investigating the clinical characteristics, angioarchitecture, treatment strategy, and outcome of PMAVF in pediatric patients.

Methods and materials

Nineteen children with PMAVF treated in Xuanwu Hospital between 1986 and 2007 were reviewed. The demographic data, clinical symptoms, angiographical characteristics, classification, treatment modality, and outcome were compiled and analyzed. Clinical status was evaluated according to the modified Aminoff and Logue scale.

Results

In our pediatric series of PMAVF, the mean age of diagnosis was 8.1 years (range, 0.8–13.7 years). Male predominance was found in our series (M/F ratio, 3.75:1). Eleven children (57.9%) presented with acute onset of symptoms, and eight cases (42.1%) had progressive evolution of the diseases. In 13 cases (68.4%), the fistulas were classified as type III, with type II in six cases. Four lesions (21.1%) were located in the cervical region, with 15 lesions (78.9%) in thoracolumbar region. Ten cases (II?=?2, III?=?8) were treated with embolization, and nine (II?=?4, III?=?5) with combined embolization and complementary surgery. According to the criteria of therapeutic effectiveness, 31.6% of cases (6/19) were cured, and nine patients (47.4%) had improved.

Conclusions

PMAVFs in pediatric population exhibit many characteristics in clinical and angiographical aspects, need for special considerations. Most of PMAVFs in pediatric patients are high-flow fistulas, and endovascular embolization should be the first choice of treatment. After appropriate therapy, most of children can get satisfactory outcomes.     

Continuous Video EEG for Patients with Acute Encephalopathy in a Pediatric Intensive Care Unit

Objectives

In this study, we aimed to determine the incidence of electrographic seizures among patients in a pediatric intensive care unit (PICU) presenting with acute encephalopathy. Risk factors and duration of continuous EEG monitoring needed to capture electrographic seizures were also assessed.

Study Design

Based on a NeuroICU clinical care pathway, all patients with acute encephalopathy admitted to the PICU are monitored with continuous video electroencephalogram (cVEEG) for 48?h or until the encephalopathy improves. Ninety-four consecutive patients included on the pathway over a year were identified. Mean age was 6.7?years (range 32?days?C17.9?years). Data pertaining to patient clinical information and electrographic seizures, including non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE), were extracted from a prospective database.

Results

Thirty percent (28/94) had seizures captured on cVEEG including 17 patients (18?%) with NCSE. Variables associated with electrographic seizures were age <24?months and clinical seizure(s) prior to EEG placement. The first seizure captured on cVEEG occurred in the first 24?h for the majority of patients (97?%). Acute brain injury and electrographic seizures were associated with worse outcome.

Conclusions

Electrographic seizures are common in pediatric patients with acute encephalopathy. This study supports the practice of cVEEG monitoring for at least 24?h in pediatric patients with acute encephalopathy, particularly if they are less then 24?months of age and/or if a clinical event suspicious for seizure precedes the encephalopathy.     

Comparison of subgroups based on hemorrhagic lesions between SWI and FLAIR in pediatric traumatic brain injury

Purpose

The purpose of this study was to investigate efficient ways to diagnose and predict clinical outcomes for childhood traumatic brain injury.

Methods

Hemorrhagic signal intensities in nine brain regions were observed using axial fluid-attenuated inversion recovery (FLAIR) and susceptibility-weighted imaging (SWI). After having divided the subjects into mild presentation (GCS 14–15) and moderate-to-severe presentation groups (GCS ≤13), we divided the patients into three subgroups: Subgroup I, hemorrhagic foci observed only on SWI and not on FLAIR; Subgroup II, hemorrhagic foci observed on both SWI and FLAIR in the same brain regions; and Subgroup III, any cases with additional foci on SWI in other brain regions. We investigated the clinical course and compared lesion numbers and distributions of hemorrhagic lesions on SWI among the subgroups.

Results

Three clinical variables (hospitalization period in intensive care unit, total days of hospitalization, and outcome based on Pediatric Cerebral Performance Category Scale score) showed significant relevance to the three subgroups. Subgroup I showed the fewest lesions followed by Subgroups II and III, respectively. In all three subgroups, lesions were most abundant in cortical regions. Lesion in the thalamus, basal ganglia, corpus callosum, and brainstem was least in Subgroup I and gradually increased in Subgroups II and III. Such distinction was more significant in the moderate-to-severe group when compared with the mild group.

Conclusions

In cases of pediatric traumatic brain injury, categorizing patients into one of the above three subgroups based on hemorrhagic lesions on SWI and FLAIR is a promising method for predicting patient’s clinical outcome.     

Integrated PET/MRI for planning navigated biopsies in pediatric brain tumors

Introduction

An integrated PET/MRI scanner has been used in selected cases of pediatric brain tumor patients to obtain additional metabolic information about lesions for preoperative biopsy planning and navigation.

Patients and methods

Four patients, age 9–16 years, received PET/MRI scans employing [¹¹C]methionine positron emission tomography (PET) and contrast-enhanced 3D-MR sequences for neuronavigation. PET and MR sequences have been matched for neurosurgical guidance. An infrared camera-based neuronavigation system was employed with co-registered MR and PET images fused to hybrid images for preoperative planning, stereotactic biopsy planning, and/or intraoperative guidance.

Results

All patients showed hot spots of increased amino acid transport in PET and contrast-enhancing lesions in MRI. In three of the four patients, PET hot spots were congruent with contrast-enhancing areas in MRI. In two patients, frame-based stereotactic biopsies were taken from thalamo-mesencephalic lesions. One patient underwent second-look surgery for the suspicion of recurrent malignant glioma of the posterior fossa. One incidental frontal mass lesion was subtotally resected. No complications occurred. Hybrid imaging was helpful during the procedures to obtain representative histopathologic specimens and for surgical guidance during resection. Co-registered images did match with intraoperative landmarks, tumor borders, and histopathologic specimens.

Conclusion

The integrated PET/MRI scanner offers co-registered multimodal, high-resolution data for neuronavigation with reduced radiation exposure compared to PET/CT scans. One examination session provides all necessary data for neuronavigation and preoperative planning, avoiding additional anesthesia in the small patients. Hybrid multimodality imaging may improve safety and yield additional information when obtaining representative histopathologic specimens of brain tumors.     

Thalamic tumors in children

Introduction

Thalamic tumors are rare tumors which are usually diagnosed in the pediatric age group. Although recent developments in neurosurgical practice allow more radical treatments, information about outcome is scarce for these deep-seated challenging tumors.

Methods

Medical records of 45 pediatric patients who presented with thalamic tumors between 1999 and 2012 were reviewed.

Discussion

Prognostic implication of tumor characteristics and patient variables are discussed. Although challenging, recent innovations in the field of neurosurgery and refinements in technique may prolong survival in some cases.     

Pediatric papillary tumors of the pineal region: to observe or to treat following gross total resection?

Introduction

Papillary tumors of the pineal region (PTPR) are rare brain tumors characterized by frequent local recurrences. Standardized treatment strategies are not yet defined.

Case report

We present the case of a 3-year-old girl diagnosed with PTPR. Due to her young age, adjuvant radiotherapy was omitted after gross total tumor resection. Thirty-six months later, local tumor recurrence occurred. Considering the possible risks of secondary surgery, the recurrent tumor was irradiated with proton radiotherapy. Three months later, the tumor showed near-complete remission.

Discussion

Based on this experience and other pediatric case reports from the literature, local radiotherapy might be suggested also after complete tumor resection.