Stent-assisted coiling treatment of pediatric traumatic pseudoaneurysm resulting from tumor surgery

Background: Traumatic intracranial pseudoaneurysms in children are typically the result of blunt or penetrating head injury. There are isolated reports of pseudoaneurysm as the result of intracranial aneurysm surgery in both adults and children. Treatment of these lesions, both surgically and endovascularly, can be complicated due to the known variability of arterial wall thickness in traumatic pseudoaneurysms. Case Report: We describe a child who underwent successful craniopharyngioma resection following staged surgical procedures. Follow-up imaging 8 months after the operation demonstrated an enlarging pseudoaneurysm of the left supraclinoid carotid artery. The lesion was successfully treated with stenting of the vessel and coil placement between the stent and the aneurysmal segment of the artery. Follow-up angiographic imaging 6 months later revealed complete obliteration of the aneurysm and normalization of the carotid artery lumen. Conclusion: To our knowledge, this is the first report of a pseudoaneurysm secondary to a surgical intervention in childhood that was treated with stent-assisted coiling. This strategy of vascular reconstruction is increasingly used in adults and appears safe to implement in the pediatric population. However, the long-term outcomes and the value of using an antiplatelet regimen in this young population are still to be determined.     

The use of dextroamphetamine to treat obesity and hyperphagia in children treated for craniopharyngioma

BACKGROUND: Obesity and attention difficulties are known complications following surgical treatment for craniopharyngioma. Treatments to date have been largely disappointing. OBJECTIVE: To examine the use of the central nervous system stimulant dextroamphetamine sulfate to regulate appetite and subsequent weight gain in children treated for craniopharyngioma. SETTING: A multidisciplinary clinic specializing in pediatric brain tumors. PATIENTS: Five consecutive patients with significant weight gain and poor attention following surgical treatment for craniopharyngioma were selected for the study. INTERVENTION: Children enrolled in the study were treated with dextroamphetamine, and growth, laboratory, and behavioral assessments were conducted for 24 months. RESULTS: Mean +/- SD body mass index (weight in kilograms divided by height in meters squared) increased from 21 +/- 3.5 before the operation to 32 +/- 2.8 by the start of the protocol. Body mass indices remained stable throughout the protocol. No changes were observed in insulin levels or caloric intake, but the children were more active when taking dextroamphetamine. Parents noted a significant improvement in hyperactivity (mean +/- SD, 1.2 +/- 0.4 to 0.6 +/- 0.2; P =.05), scored with the Conners Parent and Teacher Rating Scales. Teachers noted a similar improvement. CONCLUSIONS: During dextroamphetamine treatment, weight gain stabilized in children who had experienced obesity following surgical resection for craniopharyngioma. In addition, parents and teachers noted significant improvements in children's overall activity and attention. Further studies are needed to determine if the improvements are stable and if earlier intervention can prevent the initial obesity.     

儿童第三脑室肿瘤显微手术治疗临床分析

目的 探讨显微手术切除儿童第三脑室肿瘤的手术方法 与术后管理.方法 回顾性分析2005年6月至2008年6月全组17例儿童第三脑室肿瘤患儿的临床资料,其中男10例,女7例.年龄1～14岁,平均8.3岁.病程1～33个月,平均9个月,经术前评估,选择经胼胝体-穹窿间人路切除肿瘤12例、经纵裂-经终板入路显微镜下手术切除肿瘤5例.术后病理证实颅咽管瘤9例,畸胎瘤4例,生殖细胞瘤3例,星形细胞瘤1例.结果 17例第三脑室肿瘤患儿,肿瘤全切除8例(47.1%),近全切除7例(41.2%),大部切除2例(11.7%),无死亡.术后11例出现下丘脑损害并发症.结论 正确的术前评估、选择合适的手术入路、重视术后管理是手术治疗儿童第三脑室肿瘤获得良好效果的重要环节.经胼胝体-穹窿间入路术野暴露清楚,较易全切肿瘤,术后并发症少,是切除第三脑室肿瘤值得选择的手术入路.     

儿童第三脑室肿瘤显微手术治疗临床分析

目的 探讨显微手术切除儿童第三脑室肿瘤的手术方法 与术后管理.方法 回顾性分析2005年6月至2008年6月全组17例儿童第三脑室肿瘤患儿的临床资料,其中男10例,女7例.年龄1～14岁,平均8.3岁.病程1～33个月,平均9个月,经术前评估,选择经胼胝体-穹窿间人路切除肿瘤12例、经纵裂-经终板入路显微镜下手术切除肿瘤5例.术后病理证实颅咽管瘤9例,畸胎瘤4例,生殖细胞瘤3例,星形细胞瘤1例.结果 17例第三脑室肿瘤患儿,肿瘤全切除8例(47.1%),近全切除7例(41.2%),大部切除2例(11.7%),无死亡.术后11例出现下丘脑损害并发症.结论 正确的术前评估、选择合适的手术入路、重视术后管理是手术治疗儿童第三脑室肿瘤获得良好效果的重要环节.经胼胝体-穹窿间入路术野暴露清楚,较易全切肿瘤,术后并发症少,是切除第三脑室肿瘤值得选择的手术入路.     

儿童第三脑室肿瘤显微手术治疗临床分析

目的 探讨显微手术切除儿童第三脑室肿瘤的手术方法 与术后管理.方法 回顾性分析2005年6月至2008年6月全组17例儿童第三脑室肿瘤患儿的临床资料,其中男10例,女7例.年龄1～14岁,平均8.3岁.病程1～33个月,平均9个月,经术前评估,选择经胼胝体-穹窿间人路切除肿瘤12例、经纵裂-经终板入路显微镜下手术切除肿瘤5例.术后病理证实颅咽管瘤9例,畸胎瘤4例,生殖细胞瘤3例,星形细胞瘤1例.结果 17例第三脑室肿瘤患儿,肿瘤全切除8例(47.1%),近全切除7例(41.2%),大部切除2例(11.7%),无死亡.术后11例出现下丘脑损害并发症.结论 正确的术前评估、选择合适的手术入路、重视术后管理是手术治疗儿童第三脑室肿瘤获得良好效果的重要环节.经胼胝体-穹窿间入路术野暴露清楚,较易全切肿瘤,术后并发症少,是切除第三脑室肿瘤值得选择的手术入路.     

Clinical outcome in children with craniopharyngioma treated with primary surgery and radiotherapy deferred until relapse

BACKGROUND: To report the clinical outcome in children with craniopharyngioma following primary surgery and deferred radiotherapy at relapse. PROCEDURE: Twenty-five children with craniopharyngioma were treated with primary surgery. Total resection was achieved in 19 children (76%), while in 24% total resection was not achieved due to tumor adhesion to adjacent critical structures. None of these children received radiation therapy immediately after total or sub-total resection. Radiotherapy was delivered at the time of relapse in 11 patients (44%). RESULTS: The median follow-up from primary surgery was 10 years (3-16 years). The 14 year overall survival was 100%. Tumor recurrence was observed in (12/25) 48% at a median interval of 17 months. Tumor recurrence following total resection was 6/19 (32%) compared to 100% (6/6) following sub-total resection, and radiotherapy. The 2, 3, and 6 years relapse-free survival following initial surgery was 72, 55, and 50%, respectively. Univariate analysis revealed only extent of surgery to be significant for local recurrence (P < 0.0001). The sequelae observed in these patients included panhypopituitarism (100%), appetite disorders and hypothalamic obesity (32%), neuropsychological and behavioral disorders (20%), and sleep disorders (12%). Majority of children with non-endocrine complications had a local recurrence requiring further surgery and radiotherapy. CONCLUSIONS: The two standard treatment options in children with craniopharyngioma are primary surgery and sub-total resection followed by radiotherapy. In certain subgroups of patients such as those with large tumors and hypothalamic extension, primary surgery is associated with a high incidence of complications and high failure rates. We recommend utilization of an individualized risk-based treatment approach, that attempts to maximize cure rates without compromising long-term functional outcome in children with craniopharyngiomas.     

Blister-like supraclinoid internal carotid artery pseudoaneurysm in a 15-year-old male: case report and review of the literature

With an incidence of less than 1-3 per million, pediatric aneurysms are rare clinical entities. A traumatic etiology is implicated in a large proportion of these cases, leading to the formation of both 'false' and 'true' aneurysms. These occur most often in the distal circulation, but have also been described in the supraclinoid distal internal carotid artery (ICA). Blood blister aneurysms are also found in this location; however, they have not been described in the pediatric population. We report the case of a 15-year-old male who presented following cranial trauma with diffuse basal subarachnoid hemorrhage and limited additional intracranial pathology. Computed tomography angiography demonstrated a small, 2-mm blister-like aneurysm arising from the dorsal surface of the left supraclinoid ICA at a non-branching site. Despite early endovascular treatment with Guglielmi detachable coils, the lesion continued to grow over subsequent studies, necessitating open surgical clipping. At the time of surgery, gross pathology of the native ICA was observed, raising the possibility of a preexisting blood-blister aneurysm. We review the epidemiology, pathophysiology and diagnostic considerations of these lesions. The endovascular and surgical management of these complex non-branching supraclinoid ICA aneurysms is also discussed.     

儿童颅咽管瘤术后迟发性低钠血症及治疗探讨

为探讨儿童颅咽管瘤术后迟发性低钠血症的发生、发展及治疗，以提供合理的处理方法，对12例颅咽管瘤术后患儿血电解质、尿和血常规变化和治疗方法进行分析。结果为12例中发生迟发性低钠血症6例，出现低钠血症的时间为术后3天－8天，均伴有低血钾、低血氯等。通过限制补液量、补充高渗氯化钠和使用速尿等治疗后，血钠水平在术后4－14天恢复正常。提示儿童颅咽管瘤术后迟发性低钠血症较为多见，术后2周内应严密监测血电解质和血、尿渗透压，不宜过早使用抗利尿激素制剂。     

Assessment of airways compression by MR imaging in children with aneurysmal pulmonary arteries

Magnetic resonance imaging (MRI) has an established role in the accurate and non invasive assessment of airways compression by congenital vascular rings and pulmonary artery slings, making angiography of these lesions unnecessary [1, 2]. This role can be broadened to encompass other vascular compressive lesions, as in the two pediatric patients described here with aneurysmal pulmonary arteries of different etiology, one congenital and the other acquired.     

手术治疗31例小儿颅咽管瘤临床分析

目的：为了提高对儿童颅咽管瘤的诊断率以及减少术后并发症的发生,该研究探讨小儿颅咽管瘤的诊断方法、手术方式及术后并发症的防治。方法：回顾性分析31例小儿颅咽管瘤的临床表现、手术方法和术后并发症治疗的经验。结果：31例患儿主要临床表现为：头痛,视力下降,生长发育迟缓等。CT和MRI可确诊颅咽管瘤。31例颅咽管瘤中,肿瘤全切除 19例（61.3%）,次全切除5例（16.1%）,大部分切除7例（22.6%）。术后出现尿崩症者19例（61.3%）,3例为长期性尿崩。6例（19.4 %）出现下丘脑损伤症状。无死亡病例。随访32.5个月, 5例（16.1%）患儿复发。结论：小儿颅咽管瘤的诊断主要依据临床表现、CT和MRI检查,该病以开颅手术治疗为首选。肿瘤切除的程度应考虑降低肿瘤的复发和减少并发症的发生为原则。［中国当代儿科杂志,2009,11（8）：663-665］     

Aneurysmal bone cyst of the acromion: a case report

The case of 6-year-old girl with an asymptomatic aneurysmal bone cyst of the acromion is reported. Such tumors are rarely located in the scapula and are especially rare in the acromion. The diagnosis was confirmed by biopsy and surgical resection of the lesion. Roentgenographic, CT and histologic features of the cyst are discussed.

     

Oral tumors and tumor-like lesions in infants and children

The aim of this retrospective study was to survey the spectrum of oral tumors and tumor-like lesions treated in a pediatric surgical unit. The clinical features and treatment outcome are presented, and guidelines for management discussed. Long-term follow-up was carried out both by re-examination and by means of a questionnaire. A total of 95 patients were encountered over a 30-year period. The age at presentation ranged from 1 day to 16 years, and the male to female ratio was 0.7:1. The lesions were located predominantly on the lips (22%), tongue (21%), and cheek (19%). Patients were divided into five groups based on histological diagnosis. Benign lesions accounted for 83 (87%) of the cases. Of these, 41 (43%) were benign tumors, the most common of which were the hemangiomas (17 cases). Hamartomas accounted for a further 22 benign lesions (23%), among which 12 were lymphangiomas. Furthermore, we saw 14 cases (15%) of mucoceles, ranula and dysontogenetic cysts, and a further 6 cases (6%) were classed as miscellaneous lesions. Simple surgical resection was successful in treating most benign lesions, with occasional re-excision being necessary in lymphangiomas. The long-term effects of treatment include reduction of the red volume of the lips, scarring following resection of parotid hemangiomas, a forked tongue after wedged resection, and partial facial nerve palsy. The group of 12 (13%) malignant tumors consisted of 5 rhabdomyosarcomas, 2 fibrosarcomas, 2 carcinomas of the parotid, 1 osteosarcoma, and 2 metastases. A multimodal approach was used in patients with rhabdomyosarcomas, while fibrosarcomas and parotid carcinomas were normally treated by surgical excision. Six of 12 patients with malignant tumors were alive after a median follow-up of 20.5 years. Re-examination of the malignant tumor group revealed scarring, impaired growth and function of the maxilla associated with local irradiation, and an external salivary fistula. In conclusion, while most oral and maxillofacial tumors of children are benign, malignant tumors of soft tissue, salivary glands and bones must be taken into account. There are specific aspects related to certain developmental and biological characteristics that make a mainly conservative approach preferable in these children.     

Moyamoya-like disease in Down's syndrome

We present a case of a 6-year-old girl with Down's syndrome who developed recurrent hemipareses. Cerebral angiography showed bilateral supraclinoid stenosis of internal carotid arteries and complexes of dilated collateral vessels, consistent with moyamoya disease.     

Thoracic computed tomography in absent pulmonary valve syndrome management

A neonate with absent pulmonary valve syndrome (APVS) and features of tetralogy of Fallot presented respiratory distress. The prolonged need for mechanical ventilation was an indication for surgical repair. Preoperative thoracic CT imaging showed nearly complete closure of the distal trachea, compressed by the aneurysmal dilatation of the pulmonary arteries, and its reopening after ventilator pressure was increased. Management of APVS may require high‐pressure ventilation to prevent bronchial collapse due to compression by the pulmonary arteries. In this context, thoracic CT imaging is very useful for adjusting ventilation support so that surgical repair can be performed in optimal conditions.     

Endocrine sequelae of childhood craniopharyngioma

The endocrine sequelae of 62 children with craniopharyngioma were studied retrospectively. These patients were followed for a median duration of 3 years (range 1 to 10 years). Eighteen patients had a long-term follow-up for more than 5 years (range 5 to 10 years). Complete surgical resection was achieved in 30 patients and 32 patients had residual tumor. Twenty-five patients had recurrence or progression of the residual tumor and were treated with radiotherapy. Presenting complaints suggestive of endocrinopathy were infrequent. The most common presenting symptoms were headache, nausea and vomiting, followed by growth failure. Pre-operatively, growth hormone deficiency was the most commonly encountered pituitary hormonal deficiency; however postoperatively, most children had diabetes insipidus. Multiple pituitary hormonal deficiencies were more frequently observed in children treated with extensive radical surgery than in those treated with conservative surgery and radiotherapy. The endocrine morbidity associated with craniopharyngioma and its different management modalities remains high; however, it is manageable with appropriate hormonal replacement therapy.     

Pathological Study of Postcoronary Arteritis in Adolescents and Young Adults: With Reference to the Relationship Between Sequelae of Kawasaki Disease and Atherosclerosis

To clarify whether the cardiac sequelae of Kawasaki disease (KD), postcoronary arteritis lesions can become a risk factor for atherosclerosis of the coronary arteries, six autopsy cases of patients older than 15 years of age with coronary arterial lesions caused by arteritis in childhood were examined histologically. Twenty-four arteries were inspected: 10 had no evidence of aneurysm formation, 7 arteries manifested simple dilatation of the lumen, and in 7 arteries there were aneurysms with recanalization. In the group in which there were no aneurysms, ``new intimal thickening' was observed in addition to the preexisting intimal thickening which had been caused by arteritis in the acute phase of KD. In the second group with aneurysmal arteries whose lumen remained dilated, thrombotic occlusion occurred in 4 of 6 aneurysms. In addition, advanced atherosclerotic changes (i.e., complicated lesions) were found in a 39-year-old patient. Finally, in the third group of arteries which manifested recanalized lumens after thrombotic occlusion of the aneurysms, new intimal thickening was seen on the internal side and some of them were occluded. The findings in this study suggest that aneurysms present in coronary arteries in individuals with a history of KD constitute a risk factor for atherosclerosis later in life.     

Technical aspects of Nephron-Sparing Surgery (NSS) in children with bilateral centrally located renal tumors

Bilateral Nephron-Sparing Surgery (NSS) is the gold standard as surgical treatment for children suffering from bilateral renal tumors. Whereas this approach is easy to achieve in peripheral tumors, it represents a relevant challenge in lesions that are centrally located. Involvement of the collecting system, localization deep within the renal parenchyma, and proximity to the central renal vessels are often difficult to deal with. A relevant number of patients thus receive unilateral total nephrectomy or undergo incomplete resections. However, surgery can often be performed successfully through experienced surgeons in centers of excellence, even though conditions for resection appear dismal on preoperative imaging. In this article, the authors describe technical aspects of Nephron-Sparing Surgery in complex conditions of bilateral pediatric renal tumors.     

Acute hemiplegia and cortical blindness due to moya moya disease: report of a case in a child with Down's syndrome.

We are reporting what we believe to be the first case of moya moya disease (hemiplegia associated with supraclinoid carotid stenosis and multiple cerebral telangiectasia) in a child with Down's syndrome. On cerebral angiography, multiple collateral vessels and rete mirabile (anastomosis of meningeal vessels with internal cerebral vessels) were noted, in addition to the supraclinoid carotid stenosis. Computerized tomography revealed nonobstructive hydrocephalus and findings consistent with multiple vascular insults or infarcts. It is not clear whether moya moya disease represents a true disease entity (congenital arterial dysplasia) or is a syndrome caused by nonspecific vascular reaction. Since abnormal vascular morphology has previously been described in children with trisomy 21, we suggest that the presence of these two disease entities may not be coincidental. It may represent a genetic predisposition in Down's syndrome toward vascular abnormalities, with variable expressivity which manifested itself in this case by abnormalities in the cerebral circulation.     

Severe lower tracheal stenosis in infancy.

16 infants with severe distal tracheal stenosis (TS) seen from 1978-1988 are reviewed. Diagnosis was established by endoscopy and confirmed by radiographic methods, including magnetic resonance imaging (MRI) in three cases. Types of TS ranged from segmental stenosis to complex lesions involving the carina and bronchi. Associated vascular anomalies were found in nine patients (56%). All patients needed long-term intubation or a tracheostomy (seven cases) for stenting of the airway. Patients with congenital TS (CTS) were treated by tracheal resection (two survivors), dilatation (one survivor, two non-survivors), or observation (two non-survivors). Patients with pulmonary artery sling (PAS) were treated by division of the vascular sling (three survivors, one non-survivor), or combined vascular and tracheal surgery (one non-survivor). One patient with dilated pulmonary arteries compressing both main bronchi died in spite of oxygen therapy. Two cases of compression by an anomalous aorta were managed with dilatation (one survivor, one non-survivor). One patient with a severe stricture after a tracheal resection was successfully treated by dilatation. The overall mortality was 50%. We conclude that 1. endoscopic examination of the tracheobronchial tree and thorough evaluation of associated anomalies is mandatory in symptomatic patients; 2. if indicated surgical correction is the treatment of choice for tracheal stenosis; 3. dilatation and stenting of the stenosis are invaluable tools in the management of these infants.